HomeMy WebLinkAbout20031066.tiff RESOLUTION
RE: APPROVE FOUR NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR
VARIOUS PROGRAMS AND AUTHORIZE CHAIR TO SIGN -ACKERMAN AND
ASSOCIATES, P.C.
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with four Notification of Financial Assistance
Awards 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 Ackerman
and Associates, P.C., commencing June 1, 2003, and ending May 31, 2004, with further terms
and conditions being as stated in said awards for the following programs:
1) Option B - Home Based Intensive
2) Mediation and Facilitation under the Intensive Family Therapy Program
Area
3) Sex Abuse Treatment
4) Lifeskills, 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
o
Weld County, Colorado, ex-officio Board of Social Services, that the four Notification of
Financial Assistance Awards for the above listed programs between the County of Weld, State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of
the Department of Social Services, and Ackerman and Associates, P.C., be, and hereby are,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said awards.
2003-1066
n0 ` c 7 ,> SS0030
FOUR NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS -ACKERMAN AND
ASSOCIATES, P.C.
PAGE 2
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.
BO OF COUNTY COMMISSIONERS
WEL OUNTY COLORADO
ATTEST: atedi
� && vid . Long, Chair
Weld County Clerk to th :o. !`'
r"` 1 .
BY: C `w Robert D. sden, Pro-Tem
FA C 'r , �
Deputy Clerk to the Board
M. J.
eile
AP D AS F • Willia H.
Jerked
my Attorn y
5/s Glenn Vaad
AL411-0\--
Date of signature:
2003-1066
SS0030
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-2001
Revision (RFP-FYC-(03010)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2003 and Ackerman and Associates,P.C.
Ending 05/31/2004 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(to a 20 hours maximum.) 2) The hourly rate will be paid for only direct face-to-face
Bilingual/Bicultural and South County services contact with the child and/or family,as evidenced by
are available. client-signed verification form,and as specified in the
unit of cost computation.
Cost Per Unit of Service 3) Unit of service costs cannot exceed the hourly, and
Hourly Rate Per $ 80.00 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 25th calendar day following
the end of the month of service. The provider must
Enclosures: submit requests for payment on forms approved by
X Signed RFP:Exhibit A Weld County Department of Social Services.
Supplemental Narrative to RFP: Exhibit B
Recommendation(s)
Conditions of Approval
Appro s: Program Official:
By CJ By
David E. Long, Chair Ju e o, Direct
Board of Weld County Co 'ssioners W County Department of Social Services
Date: Date:
o2003-/06 '
EXHIBIT "A"
INVITATION TO BID
OFF-SYSTEM BID 02-03 RFP-FYC-03010
DATE:February 19,2003 BID NO: RFP-FYC-03010
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-03010) for:Colorado Family Preservation Act--Home Based Intensive
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 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 1,2003, through May 31,2004, at specific rates for different types of service. The County
will authorize approved vendors and rates for services only. The 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
M
Delivery Date 1•w..rj !3, too3 Ce P %mmofn,Rclt
(After receipt of order) BID MUST BE SIGNED IN INK
�(sL e RCII�t- nun dO.
\ `_ • p _ TYPED OR PRINTED SIGNATURE
VENDOR U> K\Clt'\ tmek I `l�s�- oIce€.S
(Name) wri en Signature By Authorized
p • O cer or Agent of Vender
ADD -4U�i�to( TITLE�QQS\c9�r�<
ce[Elty ��l • .Q34 DATE cS — c -c
PHONE# r CI 1 O a '3 an-rS
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 32
RFP-FYC-03010 Attached A
HOME BASED INTENSIVE FAMILY INTERVENTION PROGRAM BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING
FAMILY PRESERVATION PROGRAM
2003-2004 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2003-2004
OFF-SYSTEM BID RFP-FYC-03010
NAME OF AGENCY: IN cAls:.man c.yn& ��te\aNe. g
ADDRESS: \7/ f 'nve - c.A\'- \CS \
PHONE(499 353 -- E>3 ?3 - LP
CONTACT PERSON: S k M Cx r\ TITLE: r\
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. d
A/howect' R¢p taS �,P to {I l? °o4"
12-Month approximate Project Dates: — 12-month contrac?with actual time lines of:
Start June 1,2003 Start
End May 31,2004 End
TITLE OF PROJECT: r .-rn h r. (yr Q, Sid l\p n
Cxe.. p& .
Name : .d S atut of Person Preparing Document Date
�. C:4‘1. 3 - \ °1 -03
Name an ative 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 2002-
2003 to Program Fund year 2003-2004.
Indicate No Change from FY 2002-2003 to 2003-2004
_✓ Project Description q/_ e/
✓ Target/Eligibility Populations re
f Types of services Provided to id t'CW
if Measurable Outcomes
Service Objectives
Workload Standards
/ Staff Qualifications N
✓Unit of Service Rate Computation PICA,/
I Program Capacity per Month NQ W
Certificate of Insurance
✓ Assurance Statement
--------- ----------------- --------------- ------------------ ---
Date of Meeting(s)with Social Services Division Supervisor: 9-/tit o3
Page 26 of 32
REP-FYC-03010 Attached A
Co ents by SSD Supervisor:
, � k1F;�iLL.,_/ it it ti Oil v'-/ a it.,�E ' �� ALA/ e, `Fi.,_-� rk
-LAIC - AYety-- t.9- tU_iu_< i ,-1(_t_c� ✓ ,z'ti i ,r ai !t k� (�_�i7(-- ,'
ik,thi.cli
L f a +,:- i a e d 17.,E -EN, �ti-es t ye f'ti. l 2Q( i_,E,c C-L.L e'_
;J A& 1°�,it-r tt ,rte_ 1- A P L IL `t/( Jc i_U / -�x,_ , S
Uu :, •) ,,‘,: tok '1 cic_ D<, f_,-e and Signature of SSD Supervisor Date
•
Page 27 of 32
RFP-FYC-03010 Attached A
Program Category Home Based Intensive Family Intervention Program Bid Category
Project Title A calcE .ass. Seneii9 t S
Vendor ,Q eat r "44 ASS a u a.'G... r c .
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 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
RFP-FYC-03010 Attached A
IV. MEASURABLE OUTCOMES
Provide a two-page description of your expected measurable outcomes of the project. Address the
following measurable outcomes:
A. Child remains in home at time case is closed.
B. Improvements in parental competency,parent/child conflict management and household
management competency as measured by pre and post placement functional tests.
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.
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 Home Based Intensive Family Intervention
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.
F. 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.
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. Improve Family Conflict Management-Mediation and counseling designed to resolve
conflicts and disagreements between parents and their children contributing to child
maltreatment,running away and other status offenses.
B. Improve Household Management Competency- capacity of parents to provide a safe
household environment for their children by addressing safety issues and protection of
children.
D. Improve Ability to Access Resources - services shall assist parents in learning to obtain help
from 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-03010 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. Number of hours per day, week or month. (Minimum intensity of 3 hours per week per
family.)
B. Number of individuals providing the services.
C. Maximum caseload per worker. (Minimum family caseload of 8-10.)
D. Modality of treatment.
E. Total number of hours per day/week/month.
F. Total number of individuals providing these services.
G. The maximum caseload per supervisor.
H. Insurance.
VII. STAFF QUALIFICATIONS
Provide a one-page description of staff qualifications and address, at a minimum, the following:
A. Will your staff, including supervisors,who are providing direct services have the minimum
qualifications in education and experience in Staff Manual Volume VII, Section 7.303.17, and
Section 7.0006,Q, Colorado Department of Human Services? Describe.
B. Total number of staff, including supervisors, available for the project.
C. Will your staff have received mandated new caseworker training?
D. Will your staff have knowledge in risk assessment?
E. Will your staff have completed the required State Home Based Intensive Family Services
training component?
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
Page 30 of 32
M .,: .. x Y ',., Y '% •
PROGRAM BUDGETS COMPUTERIZED ACr11AL
PROGRAM a horn?base? rT Sexuel Abuse LMa s Ib •F1,Mer Prints
TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CUENT 20 5 45 90 1
TOTAL CLIENTS SERVED 120 120 36 120 188
TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 2,400 600 1,620 3,800 188
COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) $48.00 $48.00 $48.00 $48.00 $180.00
TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $115,200 $28,800 577,760 $172,800 $30,240
ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $13,440 $3,360 36,074 $20,160 $3,528
OVERHEAD COSTS ALLOCABLE TO PROGRAM $63,380 $15,840 $42,788 $85,040 $16„832
TOTAL DIRECT,ADMINISTRATION B OVERHEAD COSTS(E+F+G) 3182,000 $48,000 3129,822 $288,000 350,400
PROFITS CONTRIBUTED BY THIS PROGRAM $0 $0 30 $0 _ 30
TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $182,000 $48,000 $126,6222 $288,000 $50,400
TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 2,40D 600 1,620 3,600 168
RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE
(J/X) $80.00 $80.00 $80.00 $80.00 $300.00
GROUPS
. 3
SEE BUDGET JUSTIFICATION SECTIONS OF EACH BID FOR EXPLANATIONS
Ce ' ton statement
I a,,pv.C`1.r.sr..`>✓w.... declare to the best of my knowledge and belief that the statements
ma this document are true and complete and that the wage rates and other factual unit costs supporting the compensation
paid o to be paid under this contract are accurate, complete and includes no duplicate costs and that I am the CEO or duly authorized agent of
Ackerman and Associates P.C.
Budget justifications to accompany bid worksheet:
The worksheets are based on 2002 income data from Jan 1 2002 through December 31
2002 for Ackerman and Associates P.C. Ackerman and Associates is Category S
Professional Corporation which does not publicly trade stock. As such we will make our
accounting data available to WCDSS services to verify the percentages below upon
written request. Approximate totals can be calculated from data given here.
For 2002 53%of the income of Ackerman and Associates was derived from core services
contracts with WCDSS. 32%was derived from insurance or patient payments, 8%from
mediation and other court related work, 3 %from other contracts and 4%from other
sources.
On the expense side salaries of employees totals 23%of expenses and payments to
provider subcontractors total 56%of expenses making salaries and fees for services
rendered by providers 79 percent of expenses. The proportion of provider fees for
services attributable to core social services payments are 57.5%of the subcontractors'
fees. Our formula for paying providers is based upon 60% of the billed fee for all work
done through Ackerman and Associates. The difference represents uncollected billing
from WCDSS based on individual disputed technical issues and items either closed or
under going review.
The remaining 21%of expenses representing slightly more than $100,000 dollars include
heat light, rent, contract labor other than providers, accounting and insurance costs, legal
services, travel, telephone, advertising, mailing supplies and other costs.
Net profits represented less than one half of one percent of gross earnings in 2002.
Do Payments from WCDSS over or under support Ackerman and Associates?
Taking the total income received by Ackerman and Associates as the base and dividing
this into the income produced by all social services core contract work produces a
multiplier of 0.53. This is to say the 0.53 time expenses not otherwise attributable to a
specific program is used to calculate the appropriate attributable expenses assigned to
WCDSS. Call this amount cost A Adding this number with the actual payment to
subcontractors from WCDSS(Cost B)and assigning .53 times salary costs(cost C)
produces a total amount called D where D is the sum of A+B+C
D represents the total amount of expenses that could justifiably be supported by funds
from social services. An amount E is the total actual payment received from WCDSS for
core services.
The ratio of D divided by E tells us if WCDSS payments supported more or less than its
appropriate share of costs of the overall work of Ackerman and Associates P.C.
L L
If DIE is greater than one than more expenses could have been assigned for WCDSS
than money was received from social services, that is to say social services programs
were a potential cost to Ackerman and Associates and fees might be raised. If D/E is less
than one then WCDSS funds are providing additional support for the agency and costs
might be lowered.
For Ackerman and Associates the ratio of D/E is 1.02 for the year 2002 as defined
above. There is no evidence that social services payments are disproportionately
supporting our business activities. Except for a small amount of disputed billing this ratio
would be closer to one.
Ackerman and Associates has never the less elected to reduce or billing fee to $80.00
dollars an hour. All of this reduced cost comes from a voluntary reduction in direct
service fees paid to our providers. While not all providers have elected to join this
voluntary reduction in payment, the majority of those who previously participated in
specific Services programs have elected to do so again. Our overhead costs are relatively
fixed or are expected to rise,. However, given the current crisis in state budgetary issues,
we hope these actions by Ackerman and Associates and its providers will provide needed
service for Weld County's residents and children in need of the services of WCDSS.
Current profit margin for 2002 was less than one half of one percent. WCDSS programs
are not expected to produce profit for us given our fee reduction of 23% at anticipated
rates of services. Note that we are offering considerable treatment capacity. If we
provided services at that capacity, then economies of scale might become apparent but we
consider this scenario unlikely given current budgetary considerations.
Snecific additional information by program
Sexual abuse—The rate provided on the bid sheet is an individual treatment rate. The
group rate is $40 per participant per group session is contained within the proposal.
Foster parent—The rate provided is a group rate. The unit of service is a two hour group
meeting as defined within the bid. Up to 168 groups will be offered. The expected cost
per participant is less than $20 per hour of group time—less if the group is larger as the
groups are being billed at a fixed rate pr group meeting. The rate for individual services if
requested by WCDSS is $80 per hour.
Home Based, IFT and Life skills—no additional budget information is provided beyond
that contained in the bid as only individual or family services are offered at the same rate.
No group services are offered under these proposals.
L C L,
Project Description, 2003-2004
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 six 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 dearly 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.
has been a home based provider during the past two years. She brings expertise
in community oriented psychology to the home based project.
Design: Implementation of our program in Weld County has been quite
successful in the last six 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 2003-2004 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.
Dr, Evelin Gomez, Ph.D., Licensed Professional Counselor holds a masters and
doctoral degree in counseling and is bilingual in Spanish, which is her first
language. She also adds clinical supervisory expertise in drug and alcohol
treatment issues to the Ackerman and Associates professional breadth of
experience.
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.
Cassie Yackley, Psy. D, L.P.C. completed her doctoral studies in psychology and
has been a home based provider during the past two years. She brings expertise
in community oriented psychology to the home based project.
c1-
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.
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/bilinqual 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.
3
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, M.A. L.P.C., Evelin Gomez,
Ph.D. L.P.C., Joyce Ackerman, Ed.D., Karen Bender, M.S., L.P.C., Valerie
Larson, M.S.W., L.C.S.W., and Cassie Yackley, M.S., L.P.C.
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.
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
s
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.
(a
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?
7
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
8
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 are Evelin Gomez, Emily Jaramillo, Valerie
Larson, and Cassie Yackley:
9
• Cassie Yackley, Psy. D., L.P.C., has worked with us in home based
treatment over the last two years. She has family and community based
experience as well in her doctoral internship and thesis research.
• 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.
• Evelin Gomez, Ph.D., L.P.C., has work experience that includes clinical
supervision of drug and alcohol issue counseling at Island Grove
Treatment Center. She has also worked with us over the past year in
home based treatment. She is fluent in Spanish.
• Emily Jaramillo, 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
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. Karen Bender, M.A., L.P.C. has extensive experience in
treating adults for domestic violence and in the treatment of adults who have
suffered sexual abuse.
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 $80 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 and another
10
licensed professional counselor 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 eight 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
2002 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$80 per contact hour.
The profit for Ackerman and Associates for all programs was 1% of gross
revenues in 2002.
Ii
The proposed cost is $80 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.
Specific standards of responsibility for the 2003-2004 year have been addressed
in the body of the proposal.
I�d-
BRANCH B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER
23 A 0004087 04/26/2002 Renewal
PSYCHOLOGISTS PROFESSIONAL LIABILITY
CLAIMS-MADE INSURANCE POLICY
NOTICE: THIS IS A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY
PURCHASING GROUP POUCY NUMBER: 45-0002000
Item DECLARATIONS CERTIFICATE NUMBER:45P- 2032570
1.
Named Insured JOYCESHOHETACKERMAN
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 05/01/2002 05/01/2003
3. COVERAGE LIMITS OF UABIUTY PREMIUM
Professional Liability $ 1,000,000 each incident I $3,000,000 aggregate $ 1,713.00
4. BUSINESS OF THE INSURED: PSYCHOLOGY
5. The Named Insured is: _ Sole Proprietor (including Independent connectors) _ 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-2167(07/00),POE-8004(05/88)(Ed.'10/93), PLE-2081
Current, PON-2003
•
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-
BRANCH B/A PRODUCER NUMBER DATE OF ISSUE - PRIOR CERTIFICATE NUMBER
23 A 0004087 03/28/2002 Renewal
PSYCHOLOGISTS PROFESSIONAL LIABILITY
CLAIMS-MADE INSURANCE POLICY
NORM IRS 6 A CLAS1SNAI POLICY,PLEASE READ 71E POLICY CAREFULLY
PURCHASING GROUP POUCY NUMBER: 45-0002000
hem DECLARATIONS CIERMIRICAlfEMINISEllt 45P 2050203
1. Named Insured SUSAN PLOCK BROMLEY
1621 13th Ave
ADDRESS Greeley,CO 80631-5415
Number&Street,Town,County,State&Zip No.) a_
2. Policy Period: 12:01 A.M.Standard Time At From: ' . ` ` To:
Location of Designated Premises ` 04/01/2002 04/01/2003
3. COVERAGE LIMITS OF LIABILITY PREMIUM
Professional Liability $ 1,000,000 each Incident $3,000,000 aggregate $ 859.00
4. BUSINESS OF THE INSURED: PSYCHOLOGY
5. The Named Insured Is: X Sole Proprietor(Including Independent conga) _ 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 foml(s)or endorsement(s). .:
PEP-2012(06/93),PLJ-2008(Rev.1W94),,PLE-8035(0W97),PLE-2167(07/00),POE-8004(05/88)(Ed:*10/93),PLE-2081
Current,PON-2003
CHICAGO INSURANCE COMPANY '.
55 E. MONROE STREET;CHICAGO, ILLINOIS 60603
Near North Insurance Brokerage ' -
REPRESENTATIVE Agent or broker la Asaodation.with Trust Risk Management Services
D
Office address: 875 N Michigan Ave
1', Sts 1900 1 ,',„
City, State,
te,Zip: Chicago;IL 80611-1803
Toll-Free Number 1.-877-6V-9700
PLP-2012(06/93)
•
eMEMORANDUM OF URANCE Date Issued
11/19/2002
Memorandum Holder This memorandum is issued as a matter
of information only and confers no
ACKERMAN & ASSOCIATES ATTN DONNA 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
1776 West Lakes Parkway Covered Person (Status) Owner
West Des Moines, Iowa 50398 EMILY L JARAMILLO-BANSBERG MA 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 is subject to all the terms, exclusions and conditions of such Certificate. The limits shown
may have been reduced by paid claims.
Certificate
Type of Insurance Number Effective Date Expiration Date Limits
Professional Liability each incident 1,000,000
or occurrence
Occurrence 80M-4003488 11/01/2002 11/01/2003 3,000,000
in the aggregate
General Liability each incident
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 mall such EMILY L JARAMILLO-BANSBERG MA
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:
t44 e ,r
Account Number: CO KERL 1750 Date: 1/24/03 Initials: GRETCHEN
CERTIFICATE OF INSURANCE
EXECUTIVE RISK SPECIALTY 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:
LAURENCE P. KERRIGAN,
PH.D.
1750 25TH AVE.
SUITE /101
GREELEY, CO 80634
Type of Work Covered: PROFESSIONAL PSYCHOLOGIST
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 008-1766682 12/01/02 12/01/03 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: LAURENCE P. KERRIGAN,
PH.D.
Address: 1750 25TH AVE.
SUITE #101 •
GREELEY, CO 80634 Au orized Representative
Issue Date: 01/11/02
<���� The Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
i&i ante INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust,Inc.
5999 Stevenson Avenue AU msyi'ar£
Policy Number: CL13187602 Administered by: Alexandria,VA223043300 TRUST
Tel Free:1.800347.6647 x284
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Evelin D. Gomez
2. ADDRESS:
16593 East Alabama Place
Aurora, CO 80017
3. POLICY PERIOD: From: 01/16/02 To: 01/16/03
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY S 136 . 00
B. GENERAL LIABILITY S 0 . 00
TOTAL PREMIUM: $ 136 . 00
5. LIMITS OF LIABILITY: $100, 000 each Incident or each Occurrence $100, 000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl.Individual) Partnership
Corporation X Other(refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: Employed
(Rating Category) Counselor/Human Development Professional
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and
agreements contained in the following form(s)or endorsement(s): CPL-0004.0199 CPL•0005.0199 CPL-0006.0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005-0199.00
CHANGE ENDORSEMENT - I
THE RECIPROCAL ALLIANCE(RISK RETENTION GROUP)
This endorsement modifies insurance provided under the Professional Liability Occurrence Policy for
Professional Counselors and Human Development Practitioners.
The following spaces preceded by an asterisk(`l need not be completed if this endorsement and the policy have the same inception data
ATTACHED TO AND FORMING 'EFFECTIVE DATE 'ISSUED TO:
PART OF POLICY NO. OF ENDORSEMENT
Evelin D. Gomez
CL13187602 11/22/02
A. In consideration of the premium charged:(check appropriate box)
❑ 1.The name and address under Items 1.and 2.,Named Insured,on the declarations page is
deleted in its entirety and replaced by the following:
2.Item 5.,Limits of Liability,on the declarations page is deleted in its entirety and replaced by the following:
$1, 0 00, 0 0 0 Each Incident or Each Occurrence $3, 000, 000 Aggregate
The premium for this change is included in the premium shown
on the declarations unless a specific amount is shown here. Additional Premium $27. 00
❑ 3.Coverage and Premium,Item 4 on the declarations page,is deleted in its entirety and replaced by the following:
Coverage Premium
A.Professional Liability
B. In consideration of an ❑ additional premium ❑ return premium(check appropriate box)of
❑ 1.The policy period,Item 3 on the declarations page,is deleted in its entirety and replaced by the following:
Front To:
12:01 A.M.standard time at the location of the designated premises.
❑ 2.Coverage B.General Liability is 0 added ❑ deleted(check appropriate box).
Nothing herein contained shall be held to vary,alter,waive,or extend any of the terms,conditions,provisions.
agreements,or limitations of the above mentioned policy,other than as above stated.
e2. tilL 12/13/02
Authorized Representative Date
CPL-0008.0297 — 2
•
ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY
INSURANCE POLICY DECLARATIONS
Policy Number: PHCP025541 Philadelphia Indemnity Insurance Company
Administered by: CPH&Associates
727 S. Dearborn, Ste. 312
Chicago, IL 60605
Valerie Larson
2500 Haven Court
Evans, CO 80620
Affiliation: AAMFT
Professional Occupation: LCSW
Coverage Term From: (Effective Date)06/27/02 To: (Expiration Date)06/27/03
at 12:01 a.m. Standard Time at the Insured's Mailing Address shown above.
Retroactive Date (if applicable):
COVERAGE A—PROFESSIONAL LIABILITY COVERAGE LIMITS OF PREMIUM
LIABILITY
Individual—Each Incident: $1,000,000 $98.25
Aggregate: $5,000,000
Association, Partnership or Corporation—Each Incident: N/A
Aggregate: N/A
COVERAGE B—SUPPLEMENTAL LIABILITY COVERAGE
Each Incident:: $1,000,000
Aggregate: $5,000,000
COVERAGE C-NON-OWNED AUTOMOBILE(optional)
Each Occurrence:
Aggregate:
Premium(including taxes): $98.25
Policy Forms & Endorsements:
PHCP-01(03/01)
Authorized Signature
Call the Administrator to Verify Claims History at 1-800-875-1911
Issue Date: 09/21/01
`NN The Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
At Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust,Inc
5999 Stevenson Avenue ACAlt_,51
Policy Number: CL12494601 Administered by: Alexandria,VA 22304-33oo
Tel Fres:1800.347.0647 x284
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Cathleen Yackley
2. ADDRESS:
2911 12th Road
Greeley, CO 80634
3. POLICY PERIOD: From: 09/05/01 To: 09/05/02
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY S 387 .00
B. GENERAL LIABILITY S 0 . 00
TOTAL PREMIUM: S 387 .00
5. LIMITS OF LIABILITY: $1, 000, 0 0 0 each Incident or each Occurrence $3, 000, 000 in the Aggregate
6. THE NAMED INSURED IS: Sale Proprietor(incl.Individual) Partnership
Corporation X Other(refer to Item 7 below)
•
7. BUSINESS OF THE NAMED INSURED: Self-Employed
(Rating Category) Counselor/Human Development Professional
B. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and
agreements contained in the following forms)or endorsement(s): CPL-0004.0199 CPL-0005.0199 CPL-0006.0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005.0199-00
• • Issue Date: 11/26/2002
<< The Reciprocal' PROFESSIONAL LIABILITY OCCURRENCE
��Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust, Inc. ,,,
Policy Number: Administered by: 5999 Stevenson Avenue TRUST
Alexandria,VA 22304-3300
CL10073403 Toll Free: 1-800-347-6647 x284
ITEM DECLARATIONS RENEWAL CERTIFICATE NUMBER 100734 INDIVIDUAL POLICY
1. NAMED INSURED: Norma Karen Bender
2. ADDRESS: 1001 43rd Avenue#41
Greeley, CO 80634-2405
3. POLICY PERIOD: From 2/4/2003 To: 2/4/2004
12:01 A.M. Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific
premium charge or charges
COVERAGE PREMIUM
X PROFESSIONAL LIABILITY $296.40
- GENERAL LIABILITY $0.00
TOTAL PREMIUM: $296.40
5. LIMITS OF LIABILITY: $1,000,000 each Incident or each Occurrence
•
$3,000,000 in the Aggregate
6. THE NAMED INSURED IS: _ Sole Proprietor(incl. Individual) _ Partnership
Corporation X Other(Refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: COUNSELOR 0 Full Time
(Rating Category) ® Part Time Part Time(21 -30)
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,
stipulations and agreements contained in the following form(s)or endorsement(s):
CPL-0015-0102-00 CPL-0004-0197.00 CPL-0006-0102-00 CPL-0005-0197-00
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT
BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE
INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
CPL-005R-1201-00
03/12/2003 11:19 9703536134 PAGE 02
TRUCK INSURANCE EXCHANGE ��
OF COMP
HOME OFF IMISM�W0.SNIIREE BLVD AAII INSURANCE*WOOF,CAUFOR 50010
POLICY DECLARATIONS
1. RETAIL SERVICE - PREMIER
Named • DR JOYCE SHOHETACKERMAN PC
Insured - EasyPay Acct.No. Mad.Count
Malting . 1750 25TH AVE STE 101
GREELEY CO 80631 _07-04-362 04576-38-07
Address •
Agent No. Milky Number
The named Sired is an individual unless dheo ise stated:
❑wnMp ❑Corporation ❑Joint Ventura O Organization (Any other)
Type of Business DOCTOR'S OFFICE
2. Policy Period from 07/01 iO2 (not prior to lime applied for) to 07/01,03 12:01 a.m.Standard Time
If this policy thereplaces other coverage that ends at noon standard time of the same day this policy begins, this policy will not take affect
until Insurance,we will renew this policy if you other coverage ends. This pay the and renew will coatings for al ra rlea periods fellow o elect to continue premi this
rules and fame then in effect premium for each successive policy period subject to our txmniuriis,
3. Insured location same as mailing address unless otherwise stated:
4.We provide Insurance only for those coverages described below and for which a specific limit of insurance is shown.
PROPERTY
COVERAGES AND LIMITS OF INSURANCE
COVERAGES PREN NO. 001 001
BUSINESS PERSONAL PROPERTY $54,080
AUTOMATIC BUILDING INCREASE
PROPERTY DEDUCTIBLE $500
GLASS DEDUCTIBLE. 9100
TENANTS EXTERIOR GLASS INCLUDED
OUTDOOR TREES SHRUBS, PLANTS $2,500
FINE ARTS COVERAGE $2,000
ADOITIoNAL C0VSRAIIMU
CO AAE Alt Premises
•
aawi 74.
Oansr PAGE 7 OF S
7
'Atl . hto'your poliicy`with the'same numbershown;on•this'endorsements:; E4'1 �`,
2nd Edition
Named Insured• DR JOYCE SHOUT ACKERMAN PC • Agent Policy Number
Address• 1750 25TH AVE SUITE 101
GREELEY CO 80631 07-04-362 04576-38-07
• of the Company
designated in the
Declarations •
Insured
Location
-(Same as above unless otherwise staled here)
Effective Dale 07/31/96 .Limit of Liability.$ 1,000,000 each occurrence
$ 1,000,000 Annual Aggregate
•ADDITIONAL•INSURED ENDORSEMENT
(SPECIAL SENTINEL)
In consideration of the premium we agree with you to the following:
1. The insurance provided by this policy for bodily Injury liability and property damage liability under Coverage -
D—Business Liability insurance will also apply to the additional insured named below, but only with respect
to an occurrence arising out of the ownership, maintenance or use of that part of the Insured location
occupied by you.
2. This insurance does not apply to:
(a) Any occurrence which takes place after you cease to occupy the Insured location.
(b) Any structural alterations, new construction or demolition operations performed by or for any additional
insured named below.
• 3. The additional insured will not be construed or deemed to be a subscriber to the Company issuing this policy.
4. The additional insured will not be or become liable for any premium payments due upon this policy.
5. If this policy is terminated for any reason we will give 30 (THIRTY) days notice
in writing to the additional insured named below.
•
This endorsement is part of your policy. It supersedes and controls anything to the contrary. II is otherwise
subject to all other terms of the policy.
STATE OF COLORADO
Additional C/0 WELD COUNTY SOCIAL SERVICES DEPT
Insured .
ATTN: JUDY GRIECO
PO BOX A
• GREELEY CO 80632 Countersigned
Authorized Representative e
IF �iYLLP0,II�
�•4P5YP y
91.,103 2Nd EDITION 695 1501 N.95 1501 • �-••,
03/12/2003 11:19 9703536134 PAGE 83
COVERAGE EXTENSIONS - Optional NI her Limits of Insurance Per Occurrence
� an Promba
ACCOUNTS RECEIVABLE
VALUABLE PAPERS $25,000
OFF PREMISES PERSONAL PROPERTY 9$5,000
ss,000
.OPTIONAL COVERAGES: We provide Insurance for those Donal Coverages described below.
COVERAGE Ail Premises
OUTDOOR SIGNS
57,500
EMPLOYEE DISNONESTY
MONEY AND SECURITIES *10,000 9500 DEDUCTIBLE
elo,000 ssoo DEDUCTIBLE
•
LIABILITY AND MEDICAL PAYMENTS - Except for Fire Legal Liability, each paid claim for the following
coverage reduces the amount of Insurance we provide during the applicable annual period. Please refer to
Paragraph 0.4. of the Liability Coverage Form.
COVERAGE
LIABILITY LIAM OF INSURANCE
91
MEDICAL EXPENSES ,000,000
TENANTS LIABILITY 75,000 PER OCCUR
175,000 PER OCCURREN
CE
pcifrobes}lddels
No. Modaaue Holder Name, Address
c,
•
•
•
ow.
Count m109d I -loBY
Z.
)
WON MO (A )
Cam PM! s OF
03/12/2003 11:19 9703536134 PAGE 04
Policy Number. 04576-38-07 Effectve Date: 07/01/02
Policy Forms and Endowments attached at inception:
£3452-ED1 BPO0021299 BP00060197 8P00090197 BP04170196
BP0434O197 BP04390196 BP04550197 E6036-ED1 E0207-ED1
E3342-ED1 25-2110 25-2614 IL01690498 I1402280498
IL02290187 E4009-ED2 BP05110102 BP05130102 25-2880
8P04070187 BP12030689 E6306-ED1 E8162-ED4 £7123-ED1
E3020-ED1
Countersigned g Alt By goat
(Date) (Authorized Representative)
HOBO 7-0e
MOON PAGE S OF
03/12/2003 11:19 9703536134 pA( 05
TRUCK INSURANCE EXCHANGE
MEMBERS OF THE FARMERS INSURANCE GROUP OF COMPANIES
HOME OFFICE:MOO WILSHIRE BLVD.,LOS ANGELES,CALIFORNIA 00010
COMMON POLICY DECLARATIONS
RETAIL SERVICE — PREMIER
1. DR JOYCE SHOHETACKERMAN PC
Named •
Insured - 1750 25TH AVE STE 101 EasyPay Acct No. Prod.Count
Marling •
Address • GREELEY CO 80631 07-04-362 04576-38-07
Agin No. Policy Number
The named Insured Is an individual unless otherNrise stated:
a Partnership DE Corporation O Joint Venture El Otganization (Any other)
Typed Business DOCTOR'S OFFICE
2: Policy Period from 07/01/02 (tot prior to time applied for)to 07/01/03 12:01 a.m. Standard Time
If this policy replaces other oath the other coverage ends.
ends at noon standard time of the same day this policy begins, this policy will not take effect
ds. This policy will continue for successive pulley periods as fallen If wa elect to continue this
insurance, we will renew this policy if you pay the required renewal premium for each successive policy period subject to our premiums.
rules and forms then in effect.
THIS POLICY CONSISTS OF THE FOLLOMRNG COVERAGE PARTS LISTH) BELOW AND FOR WHICH A PREMIUM IS INDICATED. This
PREMIUM MAY BE SUBJECT TO CHANGE.
Premium After Applicable Discount and Modification
BUSINESSONNE&S POLICY 6771.00
TOTAL
SEE INVOICE ATTACHED
Farms applicable to all Coverage Parts: •
IL12011185 11.00030498 56-5166 IL00171198
CoUMaaigmS 6Ii7i/oZ. W - t$ 11444,11
.
(Date) (Authorized Representative) .• ,
waif sad
awn son ca NM .
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-17000
Revision (RFP-FYC-03008)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2003 and Ackerman and Associates P.C.
Ending 05/31/2004 Mediation and Facilitation under the Intensive Family Therapy
Program Area
1750 25th Avenue Suite 101
Greeley, CO 80634
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial Assistance
Award is based upon your Request for Proposal(RFP).
Service components include (1)identification of The RFP specifies the scope of services and conditions
extended family for family planning meetings, (2) of award. Except where it is in conflict with this
mediation services in a five-hour model, (3)address in NOFAA in which case the NOFAA governs, the RFP
appropriate families a very specific short-term treatment upon which this award is based is an integral part of the
goal that must be resolved in order to either avoid action.
placement or allow reunification. Services to a maximum
of 10 families per month, average capacity is 6 families Special conditions
per month,average stay is a maximum of 5 hours. 1) Reimbursement for the Unit of Services will be based on
Bilingual-bicultural and South County services available. an hourly rate per child or per family.
2) The hourly rate will be paid for only direct face to face
Cost Per Unit of Service contact with the child and/or family, as evidenced by
Hourly Rate Per Unit of Service $80.00 client-signed verification form, and as specified in the
unit of cost computation.
3) Unit of service costs cannot exceed the monthly and
Enclosures: yearly cost per child and/or family.
X Signed RFP:Exhibit A 4) Payment will only be remitted on cases 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 25`" 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 fficial:
By By
David E. ong, Chair Judy rieg irector
Board of Weld County Co 'ssioners Weld unty Department of Social Services
Date: 430-aYZ.13 Date: 9la,y I(,3
O2at3-RD6(0
I
EXHIBIT "A"
INVITATION TO BID
OFF-SYSTEM BID 02-03 RFP-FYC 03008
DATE:February 19,2003 BID NO: RFP-FYC-03008
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-03008) for:Colorado Family Preservation Act--Intensive Family Mediation
and Facilitation under the Intensive Family Therapy Program
Area—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 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, 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 Intensive Family Mediation and Facilitation
program under the Intensive Family Therapy Program area must provide for therapeutic intervention through
one or more qualified family therapists,typically with all family members, to improve family communication,
function, and relationships. This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date /,^^1r A /3/x00 3 t(\iSman y� .
(After receipt of order) BID MUST BE SIGNED IN INK
cak@ � 10�. . P len n 1t1
T D bR PRINTED SIGNATURE
VENDOR i\ 1Nkr11GYl GY\& RWV.ViCi S +� Cj CSILQ IXr��� kCtiO.
(Name) Han written Signature By Authorized
Officer or Agent of Vender
ADDRESS 1 O � h - SU\\&lC I TITLE tU \C01
( Pet CU. (�31'1 DATE ; - 1a_ 3 / 't
J
PHONE# 1'1 o -3�3 '(23`73
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 32
RFP-FYC-03008 Attached A
INTENSIVE FAMILY THERAPY MEDIATION/FACILITATION PROGRAM BID PROPOSAL
FAMILY PRESERVATION PROGRAM
2003-2004 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2003-2004
OFF-SYSTEM BID 02-03 RFP-FYC-03008
NAME OF AGENCY: 1�C1+Q l� l Ct n eon �sQd�a c g
ADDRESS: \`rno• 2.'SN\-r ls \O\ Ca cee`�y )CL dQ $Qb3't
PHONE: 4( I Cac� 3 ac)_a
CONTACT PERSON: (4� �C� ,rye a r> TITLE: �i Q�t\ r4,g h-4V
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Mediation/Facilitation Program must
provide for solution-focused therapy through one or more qualified therapists,typically with all family members, to resolve
conflicts and disagreements within the family contributing to child maltreatment,running away,and to the behavior
constituting status offenses.
12-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1,2003 — Start
End May 31,2004 End
TITLE OF PROJECT: li
NYtrCu l O1.\=�f3,n
AMOUNT REQUESTED: up to f yi/000.00 pit-pt c . ph rn
Nam and ignature of Person Preparing Document Date
t. . . _ . 3 -
Nam and ignatthe 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 2002-
2003 to Program Fund Year 2003-2004.
Indicate No Change from FY 2002-2003 to 2003-2004
/ Project Description R!/ i w •
/ Target/Eligibility Populations
/ Types of services Provided
/ Measurable Outcomes
./ Service Objectives
/ Workload Standards
Staff Qualifications
Unit of Service Rate Computation
Program Capacity per Month
/ Certificate ofInsurance
f Assurance Statement
Page 26 of 32
RFP-FYC-03008 Attached A
-613
Date of Meeting(s)with Social Services Division Supervisor:
Coptents by SSD Supervisor:
a I.
P L
1) J
� .(A , 0 ; (LiOJ 1 , LLJ :) r<1.,21 _C5
Name and Signature of SSD Supervisor Date
Page 27 of 32
RFP-FYC-03008
Attached A
Program Category Intensive Family Mediation and Facilitation under the Intensive Family Therapy Program
Area Bid Category Project Title Air .e -rrect i. t. FT h�p�. o,.. 4.(, rat y' !z tS•C(,�, f
or
rhA. e-.'% J. 4SSoGlk.l, /°C .
PROJECT DESCRIPTION
Please provide a one page brief description of the project.
II. TARGET/ELIGIBILITY POPULATIONS
Please provide a one page brief description of the proposed target/eligibility populations. At a
minimum your description must address:
A. Total number of clients to be served.
B. Total individual clients and the children's ages.
C. Total family units.
D. Sub-total of individuals who will receive bicultural/bilingual services.
E. Sub-total of individuals who will receive services in South Weld County.
F. Sub-total of individuals who will have access to 24-hour services.
G. The monthly maximum program capacity.
H. The monthly average capacity.
I. Average stay in the program(weeks).
J. Average hours per week in the program.
III. TYPE OF SERVICES TO BE PROVIDED
Please provide a two-page description of the types of services to be provided. Please address if your
project will provide the service minimums as follows:
A. Solution-focused therapy that is designed to resolve conflicts and disagreements within the
family contributing to child maltreatment,running away, and to the behavior constituting
status offenses. Service is goal specific and limited to five(5)hours of therapy per referral.
Services are limited to therapy services only, and do not include treatment services.
Also, provide your quantitative measures as they directly relate to each service. At a minimum,
include a number to be served in each service component. Describe your internal process to assure
that FYC resources will not supplant existing and available services in the community; e.g. mental
health capitation services,ADAD and professional services otherwise funded.
W. MEASURABLE OUTCOMES
Please provide a two-page description of your expected measurable outcomes of the project. Please
address the measurable outcomes for each area as described below:
A. Children receiving services do not go into placement.
Page 28 of 32
RFP-FYC-03008
B. Families remain intact. Attached A
C. Reunification of children with families.
D. Improvements in parental competency,parent/child conflict management as determined or
measured by pre and post placement functional tests.
E. More cost efficient services through the Intensive Family Therapy Program than the
placement of the child.
F. Therapeutic outcomes include fundamental changes in the family functioning and dynamics.
Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate,
and monitor each quantitative measure.
V. SERVICE OBJECTIVES
Please provide a one-page description of your expected service objectives and quantitative measures.
Please address, at a minimum, the following ways the project will:
A. Improve Family Conflict Management-Mediation and counseling designed to resolve
conflicts and disagreement within the family contributing to child maltreatment, running away
and other offenses.
B. Improve Parental Competency- capacity of parents to maintain sound relationships with their
children and provide care,nutrition,hygiene, discipline, protection, instructions, and
supervision.
C. Improve Ability to Access Resources - services shall assist parents to work with other sources
in the community and within the local, state, and federal governments.
D. Address specific referral issue(s)—services shall be solution focused and address issues
specified by the Department of Social Services.
Describe the methods you will use to measure, evaluate, and monitor each service objective.
VI. WORKLOAD STANDARDS
Please provide a one-page description of the project's workload standards and quantitative measures.
Please address, at a minimum, the following areas:
A. Number of hours per day, week or month.
B. Number of individuals providing the services.
C. Maximum caseload per worker. (Generally 12 families per worker. Eight to 10 families per
worker if the worker provides case management services to the families on the caseload.)
D. Modality of treatment
E. r Total number of hours per day/week/month(Minimum average of two hours of service per
family per week.
F. Total number of individuals providing these services.
G. The maximum caseload per supervisor. (Minimum of 6 workers per supervisor.)
Page 29 of 32
RFP-FYC-03008 Attached A
H. Insurance.
VII. STAFF QUALIFICATIONS
Please provide a one-page description of staff qualifications and address, at a minimum, the
following:
A. Will your staff, including supervisors, who are providing direct services have the minimum
qualifications in education and experience as defined in Staff Manual Volume VII, Section
7.303.17, and Section 7.000.6,Q, Colorado Department of Human Services. Describe.
B. Total number of staff, including supervisors, available for the project.
C. Will staff have expertise in family therapy as demonstrated by specialized training, workshops
and experience.
D. Will staff have a minimum of eight hours per year of continuing education; i.e. courses,
workshops, and/or review of literature to be documented by county.
E. Will staff have a minimum of one hour per week of clinical supervision provided by someone
with advanced skills in Intensive Family Therapy.
F. Will the clinical supervisor(s)be involved in regular training to keep current in state-of-the-art
counseling modalities and findings.
VIII. Unit of Service Rate Computation
The budget form is to be used to provide detailed explanation of the hourly or daily rate your
organization will charge the Core Services Program for the services offered in this Request for
Proposal. This rate may only be used to bill the Weld County Department of Social Services for
direct, face-to-face services provided to clients referred by the Department. Requests for payment
based on units of service such as telephone calls,no shows, travel time,mileage reimbursement,
preparation, documentation, and other costs not involving direct face-to-face services will not be
honored. Likewise, bills must be for hours or days of direct services to the client,regardless of
the number of staff involved in providing those services. Therefore, it is imperative that this rate
be sufficient to cover all costs associated with this client,regardless of the number of staff
involved in providing these services.
There are two different ways to fill out the budget form. The budget can either be done manually
or by computer. Regarding the manual budget, all areas that are required to be filled in are
highlighted. The computerized budget is less work due to predefined calculations, but does
require Microsoft Excel for Weld County's predefined budget. There are highlighted areas on the
computerized budget that are required to be filled in as well. There are disks available that have
this predefined budget on it. Firms can also design its own budget form on a spreadsheet,but at
minimum, it must have all of the columns that are on the manual or computerized budget.
Explanations on how to fill out the budget form are provided below and on the following pages.
(A) This is an estimate of the total hours or days of direct, face-to-face services each client will
receive from the time he or she enters the program until completing the program. On the
manual budget, the only place to put this number is on the Program Budget worksheet. The
computerized budget requires this number to be entered on the Direct Service Cost
Page 30 of 32
PROGRAM BUDGETS COMPUTERIZED ACTUAL
PROGRAM home bend Sexual Abuse Life Mrs *Fester Prier
TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 20 5 45 30 1
TOTAL CLIENTS SERVED 120 120 38 120 188
TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 2,400 B00 _ 1,820 3,600 188
COST PER HOURS OR DAYS OF DIRECT SERVICES(E/C) $48.00 $48.00 $48.00 $48.00 $180.00
TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $115200 $28,800 $77,780 $172,800 $30,240
ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $13,440 $3,380 $8,074 $20,180 $3,528
OVERHEAD COSTS ALLOCABLE TO PROGRAM $63.360 $15,840 $42,788 $95040 $18,832
TOTAL DIRECT,ADMINISTRATION&OVERHEAD COSTS(E+F+G) $192,000 $48,000 $129,622 $288,000 $50,400
PROFITS CONTRIBUTED BY THIS PROGRAM $0 $0 $0 $0 $0
TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $192,000 $48,000 $129,822 $288,000 $50,400
TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 2,400 600 1,820 3,600 168
RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE
(J/K) $80.00 $80.00 $80.00 $80.00 $300.00
GROUPS
• J
SEE BUDGET JUSTIFICATION SECTIONS OF EACH BID FOR EXPLANATIONS lCe ' tion statement
1 o+.p4.�.C'r..,.h.,.M,�,., declare to the best of my knowledge and belief that the statements
ma this document are true and complete and that the wage rates and other factual unit costs supporting the compensation
paid o to be paid under this contract are accurate, complete and includes no duplicate costs and that I am the CEO or duly authorized agent of
Ackerman and Associates P.C.
Budget justifications to accompany bid worksheet:
The worksheets are based on 2002 income data from Jan 1 2002 through December 31
2002 for Ackerman and Associates P.C. Ackerman and Associates is Category S
Professional Corporation which does not publicly trade stock. As such we will make our
accounting data available to WCDSS services to verify the percentages below upon
written request. Approximate totals can be calculated from data given here.
For 2002 53%of the income of Ackerman and Associates was derived from core services
contracts with WCDSS. 32%was derived from insurance or patient payments, 8%from
mediation and other court related work, 3 %from other contracts and 4% from other
sources.
On the expense side salaries of employees totals 23%of expenses and payments to
provider subcontractors total 56% of expenses making salaries and fees for services
rendered by providers 79 percent of expenses. The proportion of provider fees for
services attributable to core social services payments are 57.5%of the subcontractors'
fees. Our formula for paying providers is based upon 60%of the billed fee for all work
done through Ackerman and Associates. The difference represents uncollected billing
from WCDSS based on individual disputed technical issues and items either closed or
under going review.
The remaining 21%of expenses representing slightly more than $100,000 dollars include
heat light,rent, contract labor other than providers, accounting and insurance costs, legal
services, travel, telephone, advertising, mailing supplies and other costs.
Net profits represented less than one half of one percent of gross earnings in 2002.
po Payments from WCDSS over or under support Ackerman and Associates?
Taking the total income received by Ackerman and Associates as the base and dividing
this into the income produced by all social services core contract work produces a
multiplier of 0.53. This is to say the 0.53 time expenses not otherwise attributable to a
specific program is used to calculate the appropriate attributable expenses assigned to
WCDSS. Call this amount cost A Adding this number with the actual payment to
subcontractors from WCDSS (Cost B)and assigning .53 times salary costs(cost C)
produces a total amount called D where D is the sum of A+B+C
D represents the total amount of expenses that could justifiably be supported by funds
from social services. An amount E is the total actual payment received from WCDSS for
core services.
The ratio of D divided by E tells us if WCDSS payments supported more or less than its
appropriate share of costs of the overall work of Ackerman and Associates P.C.
�,L
If D/E is greater than one than more expenses could have been assigned for WCDSS
than money was received from social services, that is to say social services programs
were a potential cost to Ackerman and Associates and fees might be raised. If D/E is less
than one then WCDSS funds are providing additional support for the agency and costs
might be lowered.
For Ackerman and Associates the ratio of D/E is 1.02 for the year 2002 as defined
above. There is no evidence that social services payments are disproportionately
supporting our business activities. Except for a small amount of disputed billing this ratio
would be closer to one.
Ackerman and Associates has never the less elected to reduce or billing fee to $80.00
dollars an hour. All of this reduced cost comes from a voluntary reduction in direct
service fees paid to our providers. While not all providers have elected to join this
voluntary reduction in payment,the majority of those who previously participated in
specific Services programs have elected to do so again. Our overhead costs are relatively
fixed or are expected to rise,. However, given the current crisis in state budgetary issues,
we hope these actions by Ackerman and Associates and its providers will provide needed
service for Weld County's residents and children in need of the services of WCDSS.
Current profit margin for 2002 was less than one half of one percent. WCDSS programs
are not expected to produce profit for us given our fee reduction of 23%at anticipated
rates of services. Note that we are offering considerable treatment capacity. If we
provided services at that capacity, then economies of scale might become apparent but we
consider this scenario unlikely given current budgetary considerations.
Specific additional information 'y program
Sexual abuse—The rate provided on the bid sheet is an individual treatment rate. The
group rate is$40 per participant per group session is contained within the proposal.
Foster parent—The rate provided is a group rate. The unit of service is a two hour group
meeting as defined within the bid. Up to 168 groups will be offered. The expected cost
per participant is less than $20 per hour of group time—less if the group is larger as the
groups are being billed at a fixed rate pr group meeting. The rate for individual services if
requested by WCDSS is $80 per hour.
Home Based, IFT and Life skills—no additional budget information is provided beyond
that contained in the bid as only individual or family services are offered at the same rate.
No group services are offered under these proposals.
LL
Project Description 2003-2004
Short Term Intensive Family Therapy
History of short term therapy services provided to WCDSS : . in
1998, we began offering short term mediation and goal oriented
short term therapy services. Ackerman and Associates, P.C. began
its program of Family Group Decision Making on February 1, 1998
for families undergoing expedited permanency planning. For
other families that met PAC eligibility criteria, we began offering
these services on June 1, 1998 This is an application to modify
components of these various services to meet the bid
requirements for five hours of limited therapy services for 2003-
2004.
Purpose and design:
We will continue to use formats and procedures developed
previously and apply these to the current fiscal year. These
therapy components have been adapted to short term therapy for
directed behavioral outcomes.
Three specific service components are offered:
Service component one: Assistance to WCDSS in identification of
extended family for family planning meetings.
The Family Group Decision Making model involves extensive
planning with the nuclear family of the index child. Ackerman
and Associates has extensive experience in this activity over the
past five years. We offer the service of helping identify
appropriate participants for family planning meetings. Based on
our accumulated experience we are in a position to efficiently
assist in identifying the extended family members who might
serve as placement for a child when parents are in active
treatment and when parental rights are likely to be terminated if
treatment fails. Five hours of services are offered to assist the
department in greatly expanding the list of relatives and friends
who may be qualified and desire to offer permanent placement
options from within the extended family.
Service component two: Mediation services will be offered in a
five hour model.
Often a specific conflict exists between two parties, either
between spouses or within an extended family. The conflict
I
contributes to conditions which imminently put a child at risk of
placement or prevent the reunification of a child with the family.
Resolution of the conflict may be expected to assist reunification
or prevent placement. We have had seven years of offering
mediation services to the department.
Service component three: The goal achievement program was
created six years ago to assist the department in short term
solution focused therapy. In the current fiscal year we propose to
deliver services within the five hour limitations of the proposed
bid. The goal of the gap program is to address, in appropriate
families, a very specific short term treatment goat that must be
resolved in order to either avoid placement or allow reunification.
The specifics requirements and desired goals of family meeting
assistance, mediation or short term goat achievement services will
be provided in detail by the caseworker and approved by the
appropriate supervisor as reflected in the referral made to
initiate these services.
Target/Eligibility Populations
Total number of clients to be served in this twelve month
program has been calculated as follows. Ten families per month
times twelve months equals one hundred and twenty families per
year. If we assume a nuclear family size of five, two adults and
three children, then the total client pool to be served is 600
individuals. Numbers presented represent maximum total s across
all three service components
Distribution of clients. Total number of clients we will serve is
approximately 120 index children or more as calculated above.
Our experience suggests that for the nuclear family we would
expect approximately 240 of these would be adult members of
the family and approximately 360 would be minors. The age
distribution of the children would tend toward the very young
children in expedited permanency planning and to older children
in PAC referrals.
Families Served. We would anticipate serving 120 family units.
Sub total who will receive biculturaVbilingual services. We have
two Hispanic members of the staff (Evelin Gomez , Ph.D., L.P.C,
and Emily Jaramillo M.A. L.P.C. ) who are fluent in Spanish. One
of the facilitator's (Joyce Shohet Ackerman) doctoral work was on
Hispanic patient's mental health treatment patterns compared to
Anglo patients in Weld County. She also has four years of direct
cross cultural experience with an American Indian population. We
anticipate we can serve up to 100 percent of the total referred in
a bicultural manner.
We have been able to and will continue to provide bilingual
services for any family who needs them.
We can provide services in South Country if Social Services can
provide a site to do such work.
Accessibility. On weekdays all providers of Ackerman and
Associates are accessible through 24 hour answering service and
pager system. On weekends, the 24 hour access reaches the
provider on call all of whom are Ackerman and Associates'
providers.
Maximum per month. The program maximum is ten families per
month.
The monthly average capacity is six families per month.
The average stay in the program is a maximum of five hours.
Types of Services Provided
We will continue to use formats and procedures developed
previously and apply these_to the current fiscal year. These
therapy components have been adapted to short term therapy for
directed behavioral outcomes.
Three specific service components are offered:
Service component one: Assistance to WCDSS in identification of
extended family for family planning meetings.
The Family Group Decision Making model involves extensive
planning with the nuclear family of the index child. Ackerman
and Associates has extensive experience in this activity over the
past five years. We offer the service of helping identify
appropriate participants for family planning meetings. Based on
our accumulated experience we are in a position to efficiently
assist in identifying the extended family members who might
serve as placement for a child when parents are in active
treatment and when parental rights are likely to be terminated if
3
treatment fails. Five hours of services are offered to assist the
department in greatlyexpandirgthe list of relatives and friends
who may be qualified and desire to offer permanent placement
options from within the extended family.
Service component two: Mediation services will be offered in a
five hour model.
Often a specific conflict exists between two parties, either
between spouses or within an extended family. The conflict
contributes to conditions which imminently put a child at risk of
ptacement_or prevent the reunification of a child_with the family.
Resolution of the conflict may be expected to assist reunification
or prevent placement. We_have had seven years of offering
mediation services to the department.
Service component three: The goal achievement program was
created six years ago to assist the department in short term
solution focused therapy. In the current fiscal year we propose to
deliver services within the five hour limitations of the proposed
bid. The goal of the gap program is to address, in appropriate
families, a very specific short tens treatment goal that must be
resolved in order to either avoid placement or allow reunification.
The specifics requirements and desired goals of family meeting
assistance, mediation or short term goat achievement services wilt
be provided in detail by the caseworker and approved by the
appropriate supervisor as reflected in the referral made to
initiate these services.
In terms of the criteria for the PAC process:
Comprehensiveness: Within the time constraints mandated by
this bid, specific referral requests will be addressed in the most
comprehensive manner feasible.
Access to other services:-Areas unableto be addressed within a
five hour period wilt be identified and referrals offered to the
family for them to continue therapy as needed
Team based Treatment: Clinical meetings on a weekly basis at
Ackerman and Associates allow therapists to confidentially
problem solve difficult issues that arise in therapy.
Conflict Resolution: Mediation is by definition a conflict
resolution technique. Short term therapy will address conflict
`1
resolution as needed based on each referral. Assistance in family
meeting planning is a specific action designed to resolve a family
crisis.
Measurable Outcomes
Measurable outcomes are of two varieties. One type is termed
formative outcomes and the other type is called summative
outcomes. Formative outcomes measure how the program is
proceeding while the treatment takes place. Summative outcomes
are the resultkof the treatment.
In terms of formative measures we have the following...
1. Did the family accept the intensive family
therapy model?
2. Was contact successfully made with all specified
parties and did those who could not attend
provide sufficient information-to the family
meeting?
3. Did the family reach a mediated agreement in
mediation?
4. Was the specified goal achieved in a short term
solution focused therapy format
This data will be extracted from the case file.
Smmative Outcomes
The following four areas should be assessed-at about
after the completion of the five hour intensive family therapy
process by the caseworker.
A. Did the child receiving services not go into
placement.
B. DicFthe remainintart?
C. Was there reunification of children with their
families? Did this take place within the nuclear family
or within the extended family?
D. Has there been an improvement in parental
competency and parent child conflict management?
Additional questions related to A-D above might
include. Was a termination hearing avoided or modified
through the use of the FGDM process? Did the index
child find a placement in the extended family? Is this
the case for siblings of the index child as well? Was a
family proposed plan adopted in while or in part by the
court? Has the proposed plan been effective over time?
E. Does the program produce fundamental change in
family dynamics? Let's define fundamental changes as
those changes that persist for two months after the
completion of therapy. It would be possible to measure
the caseworker's perception of the family in relation to
this question. At six months after the therapy is
completed basic change in family dynamics may be
present but these will be hard to quantify. Please note
that we have not budgeted for ongoing evaluation of
this project and suggested evaluations would need to be
funded and conducted separately from this proposed
work.
Service objectives
We have the following service objectives:
A. Improvement of family conflict management. Family
therapy is specifically designed to resolve conflicts that
either precipitated the likely imminent placement of the
child or which prevent the reunification of the child with
the family (particularly service components of mediation
and shorn. term therapy.) The model teaches the family how
to use its own strengths to resolve problems.
B. Improved parental competency In this treatment model
short term solution focus therapy could assist the parents
in acute issues related_to imminent placement. Long tern
changes in parental competency are unlikely given the time
limitations of the bid. Some of these parents are having
their rights terminated and a relative of the index child will
assume the parenting-responsibilities. In-these casesit is
not a question of an improvement in competency for the
biological parent. Rather the family is selecting a more
competent relative to assume the nurturing roles the
biological parenthas_faiied to provide. Service component
one can assist in identifying appropriate individuals from
the extended family for this rote.
C. The ability of the family to access resources is enhanced
by the short term therapy process and the mediation
process. The need for a specific service should become
C
apparent as the family develops the strategy to resolve the
immediate conflict in mediation or short term therapy.
The methods used to ascertain if the service objectives
have been met would be through a report by the
caseworker at six months after the completion of these
services.
Workload Standards
A. The program has a capacity of 10 families per month.
This is approximately 50 hours of therapist time per
month. There are several therapists available for this
program. Note that there is a need to continue to allow
an exemption for the program in terms of the Face-to-
Face rule usually within the PAC programs for the work
done in identifying family resources for family group
meetings. The identification of family resources relies
upon telephone contact and written or faxed follow up.
The need for telephone data gathering is also crucial for
individuals of the extended family who live large
distances away from Weld County. Telephone contacts
have included California, Utah, Washington, New
Mexico, Arizona, Nebraska, Kansas, Wyoming, South
Dakota, Florida, and other states under family group
decision making. Extensive contact around Colorado
including the western slope and southern Colorado has
occurred by phone_Work has also occurred by phone
with Mexico. These costs are built into our
administrative portions of the bid.
B and C. there are eight providers who staff Ackerman and
Associates.
Joyce Ackerman, Ed.D. who supervises the contract is
certified as a mediator and licensed as a psychologist,
D. The modality of treatment has been described above
under the design section.
E. Hours/month The total number of therapist treatment
hours is 5 per family. This totals to 50 hours per month for
ten families pre month. A total of 600 hours per year is
projected.
7
F. Staff There are eight individual providers supported by two
office professionals in the practice.
G. Supervisor The contract would be supervised by Joyce
Shohet Ackerman, Ed.D. who monitors the project for
compliance.
Staff Qualifications
A. and B. Staff Qualifications Eight staff are available for the
project. They exceed the minimum qualifications specified
as documented below. The staff are: Joyce Shohet
Ackerman, Ed.D., Licensed Psychologist and mediator;
Emily Jaramillo, M.A., L.P.C., Karen Bender, M.A., L.P.C.,
and Susan Bromely, Psy.D. D., Licensed Psychologist, Cassie
Yackley Psy.D., L.P.C., Valerie Larson M.S.W, L.C.S.W.,
Evelin Gomez, Ph.D., L.P.C. and Larry KerriganPh:D.,
Licensed psychologist.
C. Training The staff has extensive training in family therapy
and mediation as documented by their extensive work
experience. Collectively, the eight providers have held licenses in
their field for a total of more than 60 years. Resumes are
available if desired.
D. Continuing education As a part of their work in the private
sector all providers in this-group-maintain continuing-
education programs more than the minimum eight hours
required. They participate in workshops and other
activities, These continuing education requirements arise
from other contractual arrangements.
E. Supervision All providers are independently licensed and
not required to have clinical supervision. All the staff have-
advanced skills in intensive family therapy. The supervisor,
Joyce Shohet Ackerman, Ed.D. will monitor the
specifications made in this proposal.
F. Supervisor and continuing education. The supervisor of
the project is_involved in ongoing training to keep current
with her profession through advanced workshops and
seminars and as a member of the Colorado Counsel of
Mediators and the American Psychological Association.
8
Unit of service rate computation
We have chosen to offer a rate of $80 per hour of total time
per therapist. This is our current therapy rate of service for
licensed counselors and less than our rate for psychologist's
services. Actual costs of phone contact for family meetings are
difficult to estimate and are built into administrative costs for
this proposal.
Budget Justification
Ackerman and Associates, P.C. is a type S professional for
profit corporation and not a 501.c.3. We generated a profit of
1% on gross revenue for the year 2002.
BRANCH B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER
23 A 0004087 04/26/2002 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 JOYCESHOHETACKERMAN
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 05/01/2002 05/01/2003
3. COVERAGE LIMITS OF LIABILITY PREMIUM
Professional Liability $ 1,000,000 each Incident $3,000,000 aggregate $ 1,713.00
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 forms) or endorsement(s).
PLP-2012(06/93), PU-2008(Rev. 10/94),, PLE-8035(09/97), PLE-2167(07/00), POE-8004(05/88)(Ed.'10/93), PLE-2081
Current, PON-2003
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-
BRANCH B/A PRODUCER NUMBER - DATE OF ISSUE PRIOR CERTIFICATE NUMBER
23 A 0004087 03/28/2002 Renewal
PSYCHOLOGISTS PROFESSIONAL LIABILITY
CLAIMS-MADE INSURANCE POLICY
NORM 716 IS A CLASISWI E POLICY,PLEASE READ TIE POttiYY CAREFULLY
e Y
PURCHASING GROUP POLICY NUMBER: 45-0002000
Item DECLARATIONS attic 4.5P 2050203
1. Named Insured SUSAN FLOCK BROMLEY
1821 13th Ave
ADDRESS Greeley,CO 80631.5415
Number&Street,Town,County,State&Lp No.)
2. Policy Period:12:01 A.M.Standard Time At From: To:
Location of Designated Premises '04/01/2002 04/01/2003
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 eontraMots) _ Partnership _ Corporation
Other
6. This policy shall only apply to incidents which happen on or after a)the policy effective date shown on the
Declarations:or b)the effective date of the earliest claims-made policy issued by the Company to which this
policy is a renewal;or c)the date specified in any endorsement hereto. 04/05/1996
7. This policy Is made and accepted subject to the printed conditions in this policy together with the provisions, stipulations
and agreements contained in the following form(s)orendorsement(s). .
PIP-2012(06/93),PU-2008(Rev.10/94),,PLE-8035(09/97),PLE-2167(07/00),POE-8004(05/88)(Ed.'10/93),PLE-2081
Current,PON-2003
CHICAGO INSURANCE COMPANY.
55 E. MONROE STREETS CHICAGO, ILLINOIS 60603
,:.;.1 4 i
Near North Insurance Brokerage
REPRESENTATIVE Agent or broker in_Soaalion:with Trust Risk Management Services
Office address: 875 N Michigan Ave
1 : 518� 3'tI t ;, '
City, State, •
Zip Chicago,IL 60611-1603
Toll-Free Number 1:677-637-9700
PLP-2012(06/93) !' APA
Date Issued
11/19/2002
Memorandum Holder This memorandum is issued as a matter
of information only and confers no
ACKERMAN & ASSOCIATES ATTN DONNA 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
1776 West Lakes Parkway Covered Person (Status) Owner
West Des Moines, Iowa 50398 EMILY L JARAMILLO-BANSBERG MA 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 is subject to all the terms, exclusions and conditions of such Certificate. The limits shown
may have been reduced by paid claims.
Certificate
Type of Insurance Number Effective Date Expiration Date Limits
Professional Liability each incident 1,000,000
or occurrence
Occurrence 8014-4003488 11/01/2002 11/01/2003 3,000,000
in the aggregate
each incident
General Liability or occurrence
Occurrence in the aggregate
Should the above described Certificate be canceled Insured
oefore 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 JARAMILLO-BANSBERG MA
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:
e stiCvtev
Account Number: CO KERL 1750 Date: 1/24/03 Initials: GRETCHEN
CERTIFICATE OF INSURANCE
EXECUTIVE RISK SPECIALTY 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:
LAURENCE P. KERRIGAN,
PH.D.
1750 25TH AVE.
SUITE #101
GREELEY, CO 80634
Type of Work Covered: PROFESSIONAL PSYCHOLOGIST
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 008-1766682 12/01/02 12/01/03 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: LAURENCE P. KERRIGAN,
PH.D.
Address: 1750 25TH AVE.
SUITE #101 •
GREELEY, CO 80634 Au orized Representative
Issue Date: 01/11/02
<N e Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
>>�Th Alhance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust,Inc.
5999 Stevenson Avenue ACA u.s4CE
Policy Number: CL13187602 Administered by: Alexandria,VA 223043300 TRUST
To8 Free:1.800-347.6647 x284
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Evelin D. Gomez
2. ADDRESS:
16593 East Alabama Place
Aurora, CO 80017
3. POLICY PERIOD: From: 01/16/02 To: 01/16/03
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY S 136 . 00
B. GENERAL LIABILITY $ 0 . 00
TOTAL PREMIUM: $ 136 . 00
5. LIMITS OF LIABILITY: $100, 000 each Incident or each Occurrence $100, 000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl.Individual) Partnership
Corporation X Other(refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: Employed
(Rating Category) Counselor/Human Development Professional
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and
agreements contained in the following form(s)or endorsement(s): CPL-0004.0199 CPL•0005.0199 CPL-0006.0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005.0199.00
CHANGE ENDORSEMENT - I
THE RECIPROCAL ALLIANCE(RISK RETENTION GROUP)
This endorsement modifies insurance provided under the Professional Liability Occurrence Policy for
Professional Counselors and Human Development Practitioners.
The following spaces preceded by an asterisk()need not be completed if this endorsement and the policy have the same inception date.
ATTACHED TO AND FORMING 'EFFECTIVE DATE 'ISSUED TO:
PART OF POLICY NO. OF ENDORSEMENT
Evelin D. Gomez
CL13187602 11/22/02
A. In consideration of the premium charged:(check appropriate box)
❑ 1.The name and address under Items 1.and 2.,Named Insured,on the declarations page is
deleted in its entirety and replaced by the following:
• 2.Item 5.,Limits of Liability,on the declarations page is deleted in its entirety and replaced by the following:
$1, 000, 000 Each Incident or Each Occurrence $3, 000, 000 Aggregate
The premium for this change is included in the premium shown
on the declarations unless a specific amount is shown here. Additional Premium $27 . 00
❑ 3.Coverage and Premium,Item 4 on the declarations page,is deleted in its entirety and replaced by the following:
Coverage Premium
A.Professional Liability
8. In consideration of an ❑ additional premium 0 return premium(check appropriate box)of
❑ 1.The policy period,Item 3 on the declarations page,is deleted in its entirety and replaced by the following:
From: To:
12:01 A.M.standard time at the location of the designated premises.
❑ 2.Coverage B.General Liability is 0 added ❑ deleted(check appropriate box).
Nothing herein contained shall he held to vary,alter,waive,or extend any of the terms,conditions,provisions.
agreements,or limitations of the above mentioned policy,other than as above stated.
/G[ J 02• e._ 12/13/02
Authorized Representative Date
CPL-0008.0297 - 2
ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY
INSURANCE POLICY DECLARATIONS
Policy Number: PHCP025541 Philadelphia Indemnity Insurance Company
Administered by: CPH &Associates
727 S. Dearborn, Ste. 312
Chicago, IL 60605
Valerie Larson
2500 Haven Court
Evans, CO 80620
Affiliation: AAMFT
Professional Occupation: LCSW
Coverage Term From: (Effective Date)06/27/02 To: (Expiration Date)06/27/03
at 12:01 a.m. Standard Time at the Insured's Mailing Address shown above.
Retroactive Date(if applicable):
COVERAGE A—PROFESSIONAL LIABILITY COVERAGE LIMITS OF PREMIUM
LIABILITY
Individual—Each Incident: $1,000,000 $98.25
Aggregate: $5,000,000
Association, Partnership or Corporation—Each Incident: N/A
Aggregate: N/A
COVERAGE B—SUPPLEMENTAL LIABILITY COVERAGE
Each Incident:: $1,000,000
Aggregate: $5,000,000
COVERAGE C-NON-OWNED AUTOMOBILE(optional)
Each Occurrence:
Aggregate:
Premium (including taxes): $98.25
Policy Forms&Endorsements:
PHCP-01(03/01)
(so Pig
Authorized Signature
Call the Administrator to Verify Claims History at 1-800-875-1911
Issue Date: 09/21/01
CNN The Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
/ Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust Int
5999 Stumsan Avenue
Policy Number: CL12494601 Administered by: Alexandria,VA 22304.3300 T'
Tel Frac 1.80034743947 x284
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Cathleen Yackley
2. ADDRESS:
2911 12th Road
Greeley, CO 80634
3. POLICY PERIOD: From: 09/05/01 To: 09/05/02
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY S 387 .00
B. GENERAL LIABILITY S 0 . 00
TOTAL PREMIUM: S 387 . 00
5. LIMITS OF LIABILITY: $1, 000, 000 each Incident or each Occurrence $3, 000, 000 in the Aggregate
B. THE NAMED INSURED IS: Sole Proprietor(incl.Individual) Partnership
Corporation X Other(refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: Self-Employed
(Rating Category) Counselor/Human Development Professional
8. This policy is made and accepted subject to the printed conditions of this pokey together with the provisions,stipulations and
agreements contained in the following fermis)or endorsement(s): CPL-0004.0199 CPL-0005.0199 CPL-0006.0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005.0199.00
Issue Date: 11/26/2002
��� The Reciprocal' PROFESSIONAL LIABILITY OCCURRENCE
��Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust, Inc. W
Policy Number: Administered by: 5999 Stevenson Avenue TRUST
Alexandria,VA 22304-3300
CL10073403 Toll Free: 1-800-347-6647 x284
ITEM DECLARATIONS RENEWAL CERTIFICATE NUMBER 100734 INDIVIDUAL POLICY
1. NAMED INSURED: Norma Karen Bender
2. ADDRESS: 1001 43rd Avenue#41
Greeley, CO 80634-2405
3. POLICY PERIOD: From 2/4/2003 To: 2/4/2004
12:01 A.M. Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific
premium charge or charges
COVERAGE PREMIUM
)--S- PROFESSIONAL LIABILITY $296.40
- GENERAL LIABILITY $0.00
TOTAL PREMIUM: $296.40
5. LIMITS OF LIABILITY: $1,000,000 each Incident or each Occurrence
$3,000,000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl. Individual) — Partnership
— Corporation X Other(Refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: COUNSELOR ❑ Full Time
(Rating Category) ® Part Time Part Time(21 -30)
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,
stipulations and agreements contained in the following form(s)or endorsement(s):
CPL-0015-0102.00 CPL-0004-0197-00 CPL-0006-0102-00 CPL-0005-0197-00
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT
BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE
INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
CPL-005R-1201-00
03/12/2003 11:19 9703536134 PACE 02
•
TRUC[ INSURANCE EXCHANGE
MEMBERS OF THE FARMERS 1 GROW;OF COMPARES
NOME OFFICE:MOO WILSHRE OL�ANGELES,CALIFORNIA 10010
POLICY DECLARATIONS
1. RETAIL SERVICE -. PREMIER
Named • DR JOYCE SHOHETACKERMAN PC
Insured • EasyPay ACC.No. Pod Count
. 1750 25TH AVE STE 101
Address •
07-04-362 04576-38-07
GREELEY CO 80631 Agent No. Policy Number
The named insured is an IndWIdual unless otherwise stated:
❑Partnership ❑Oaporalion akin!Venture ❑Organbatian (Arty other)
Type of Business DOCTOR'S OFFICE
2. PdwY Perbd hem 07/01/02 (not prior to lime applied far) to 07/01/03 12:01 s.m. Standard Time
B this policy replace)other coverage that ends at noon standard time of the same day this policy ins, this
ll not take affect
until the other coverage ends. This i
policy will continue far successive policy periods esInI fellows: If we policyi continue this
Insurance,we will renew this policy it you pay the required renewal premium for each successive policy period subject to our premiums,
rules and tamp then in effect
S. Insured location same as mailing address unless otherwise stated:
4.We provide Insurance only for those coverages described below and for which a specific limit of insurance is shown.
PROPERTY
COVERAGES AND LIMITS OF INSURANCE
COVERAGES PREN NO. 001 001
BUSINESS PERSONAL PROPERTY 854,080
AUTOMATIC BUILDING INCREASE qx
PROPERTY DEDUCTIBLE 8500
GLASS DEDUCTIBLE 0100
TENANTS EXTERIOR GLASS INCLUDED
OUTDOOR TREES, SHRUBS, PLANTS $2,500
FINE ARTS COVERAGE $2,000
ADDITIONAL,DOVINASBO
COVERAGE MI Premises
•
Mal 711
COMM PAGE 1 of a
: : .'At h to 90ur policy:'with the'same numbershown on,this;endorsement n , t r. V
E4f1'08k3
•
2nd Edition
Named insured• DR JOYCE SECRET ACEERMAN PC Agent Policy Number
I Address• 1750 25TH AVE SUITE 101
07-04-362 04576-38-07
GREELEY CO 80631
• of the Company
designated in the
Declarations
Insured
Location
(Same as above unless otherwise stated here) • - - - - -
Effective Date 07/31/96 Limit of Liability.$ 1,000,000 each occurrence _ ..
$ 1,000,000 Annual Aggregate
•ADDITIONAL IN$URED•ENDORSEMENT
(SPECIAL SENTINEL) •
In consideration of the premium we agree with you to the following:
1. The insurance provided by this policy for bodily Injury liability and property damage liability under Coverage -
D—Business Liability insurance will also apply to the additional insured named below, but only with respect
to an occurrence arising out of the ownership, maintenance or use of that part of the Insured location
occupied by you.
2. This insurance does not apply to:
(a) Any occurrence which takes place after you cease to occupy the Insured location.
(b) Any structural alterations, new construction or demolition operations performed by or for any additional
insured named below.
• 3. The additional insurec(will not be construed or deemed to be a subscriber to the Company issuing this policy.
4. The additional insured will not be or become liable for any premium payments due upon this policy.
5. It this policy is terminated for any reason we will give 30 (THIRTY) days notice
in writing to the additional insured named below.
•
•
•
This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise
subject to all other terms of the policy.
STATE OF COLORADO
Additional C/0 WELD COUNTY SOCIAL SERVICES DEPT
Insured
ATTN: JUDY GRIECO
PO BOX A
• GREELEY CO 80632 Countersigned
Authorized Representative e
�1YIUPC,II�
�•6v9UP;4 f
Si 4103 2ND EDITION 695 1501 K-95 1501 "'�
03/12/2003 11:19 9703536134 PAGE 03
COVERAGE EXTENSIONS - Optional HI her Limits of Insurance Per Occurrence
COUHIAGE All Premises
ACCOUNTS RECEIVABLE *25,000
VALUABLE PAPERS $25,000
OFF PREMISES PERSONAL PROPERTY $5,000
OPTIONAL COVERAGES: We provide Insurance for those Optional Coverages described below.
COVERAGE All Premises
OUTDOOR SIGNS $7,500
EMPLOYEE DISHONESTY $10,000 $500 DEDUCTIBLE
MONEY AND SECURITIES #10,000
$500 DEDUCTIBLE
LIABILITY AND MEDICAL PAYMENTS - Except for Fire Legal Liability, each paid claim for the following
coverage reduces the amount of Insurance we provide during the applicable annual period. Please refer to
Paragraph 0.4. of the Liability Coverage Form.
COVERAGE LIMITS OF INSURANCE
LIABILITY $1,000,000
MEDICAL EXPENSES $5,000 PER PERSON
TENANTS LIABILITY $75,000 PER OCCURRENCE
W a HOldels
�. MariOage Holder Name Address
H•
,Ceentasipned g iA O By
414144 >wo (A �
X771! PAC! 4 OF !
83/12/2003 11:19 9703536134 PAGE 84
Pam/Maher 04576-38-07 Effective Data 07/01/02
Policy forms and Endasemen s attached at incepMon:
E3452-ED1 8P00021299 BP00060197 ' 8P00090197 BP04170196
BP04340197 BP04390196 BP04550197 E6036-ED1 E0207-ED1
E3342-ED1 25-2110 25-2614 I1.01690498 I402280498
IL02290187 E4009-ED2 BP05110102 BP05130102 25-2880
BP04070187 BP12030689 E6306-ED1 E8162-ED4 E7123-ED1
E3020-ED1
Countersigned . //da L By $2 Lai
Mate) fnuthutsrd pepn�enlaure)
MI 7-0
MINIM PAGE ! M !
03/12/2003 11:19 9703536134 PAGE 05
•
TRUCK INSURANCE EXCHANGE
HOME MEMBERS
OF THE FARRRE INSURANCE., ANGELES,CALIFORNIA UP OF COMPANIES010
COMMON POLICY DECLARATIONS
RETAIL SERVICE — PREMIER
1. DR JOYCE SHOHETACICERMAN PC
Named .
Insured - 1750 25TH AVE STE 1 01 EasyPay Acct.No. Prod.Count
Mailing .
Address • GREELEY CO 80631 07-04-362 04S76-38-07
Agent No. Policy Number
The named Insured is an individual unless otherwise stated:
CI Partnership IN Corporation O Joint Ventura O Organization (Any other)
Type of Business DOCTOR'S OFFICE
2: Policy Period from 07/01/02 (rot prior to time applied for)to 07/01/03 12:01 a.m. Standard Time
If this policy replaces other coverage that ends at noon standard time of the same day this policy begins, this policy will not take affect
until the other coverage ends. This policy will coatings for euxessive pulley periods a fallen If we elect to continue this
insurance, we will renew this policy if you pay the required renewal premium for each successive policy period subject to our premiums.
rubs and forms then in effect
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS LISTED BELOW AND FOR WHICH A PREMIUM IS INDICATED. THIS
PREMIUM MAY BE SUBJECT TO CHANGE.
Premium After Applicable Discount and Modification
BOSINESSONNERS POLICY 0771 .00
•
TOTAL SEE INVOICE ATTACHED
Fours applicable to all Coverage Parts: •
IL12011185 IL00030498 56-5166 IL00171198
•
Counts � />r/0LBy 4,471
(fie) tive)
SeiNI sa/
CM'a A IMI Pqo 1 of 1
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-CORE-03007
Revision (RFP-FYC-03007)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2003 and Ackerman and Associates P.C.
Ending 05/31/2004 Sex Abuse Treatment
1750 25th Avenue, Suite 101
Greeley, CO 80634
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial
Time-limited, outcome focused therapy services Assistance Award is based upon your Request for
for the non-offending parent,victims,and Proposal(RFP). The RFP specifies the scope of
siblings of the victim. Individual services are in services and conditions of award. Except where it is
office. Group services provided in office, foster in conflict with this NOFAA in which case the
home, or WCDSS. The program maximum is 3 NOFAA governs,the RFP upon which this award is
new families per month with a maximum ability based is an integral part of the action.
to carry eight open cases a month. Services are
culturally sensitive. Bilingual services are Special conditions
available.
1) Reimbursement for the Unit of Services will be based
on an hourly rate per child or per family.
Cost Per Unit of Service 2) The hourly rate will be paid for only direct face-to-face
Hourly Rate Per Individual Consultation $80.00 contact with the child and/or family as evidenced by
client-signed verification form, and as specified in the
unit of cost computation.
3) Unit of service costs cannot exceed the hourly and
Enclosures: yearly cost per child and/or family.
X Signed RFP:Exhibit A 4) Rates will only be remitted on cases open with,and
Supplemental Narrative to RFP: Exhibit B referrals made by the Weld County Department of
Recommendation(s) Social Services.
Conditions of Approval 5) Requests for payment must be an original and
submitted to the Weld County Department of Social
Services by the end of the 25th calendar day following
the end of the month of service. The provider must
submit requests for payment on forms approved by
Weld County Department of Social Services.
Approv Program Official:
By By
David . ong, C air Judy 'eg , irector
Board of Weld County Co issioners Weld C unty De artment o Social Services
Date: 4-3:J -c2W3 Date: Z J3
5a3-/ow,
r
EXHIBIT "A"
INVITATION TO BID
OFF SYSTEM BID 02-03 RFP-FYC 03007
DATE:February 19,2003 BID NO: RFP-FYC-03007
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-03007) for:Colorado Family Preservation Act--Sexual Abuse 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 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)Act) 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 Sexual Abuse Treatment
Program must provide for therapeutic intervention through one or more modalities to prevent further sexual
abuse perpetration or victimization. This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date Mar cA 13 11003
(After receipt of/order) BID MUST BE SIGNED IN INK
f eliewman , �• 3.
TYPE 15 OR PRINTED SIGNATURE
VENDOR mos\ an c& i`ts�c.c:Acfr y``ec
(Name) F. ritten Signature By Authorized
O or Agent of Vendor
ADDRESS 1*i `.SO rQ Soh (jam. - 1/43.\Z.e \01 TITLE C@s)*Qt\y
Qteat\ry SN34 DATE `3 - t2- p'3
PHONE# Q'1 O - 3 - 3'x'7.3 -
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 31
• RFP-FYC-03007 Attached A
SEXUAL ABUSE TREATMENT PROGRAM BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING
COLORADO FAMILY PRESERVATION ACT
2003-2004 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2003-2004
OFF-SYSTEM BID RFP-FYC-03007
NAME OF AGENCY: 'is'sCu��m cAez,
ADDRESS: \' N, cs DS-V.\ 1{ 7 r\v — u t � \O 1 �`��o�Ly Cc, -
PHONE: (Win 2z!2 - 3 3`Z3 g p63
CONTACT PERSON:C tS),11� N a m C n TITLE: 1/4..\ t-3\
DESCRIPTION OF COLORADO FAMILY PRESERVATION ACT CATEGORY: The Sexual Abuse Treatment Program
must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse perpetration or
victimization.
12-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1,2003 Start
End May 31,2004 End
TITLE OF PROJECT: IlN\1i3Vmdn c- 1)a,, i\ \g€ N\MC AN\M VOg1-h,rr
AMOUNT REQUESTED: CC( 1-O .� I 2.9 G X2 •OO
Name d S ature of Person Preparing Document Date
`� ttn.4 3 — VD--O3
Name d Si ature 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 2002-
2003 to Program Fund year 2003-2004.
Indicate No Change from FY 2002-2003 to 2003-2004
Project Description may,
Target/Eligibility Populations
Types of services Provided
6/Measurable Outcomes
Service Objectives
,/ Workload Standards
�[ Staff Qualifications
U Unit of Service Rate Computation
Program Capacity per Month V
L Certificate of Insurance
V Assurance Statement
Page 25 of 31
03/07/2003 17:30 FAX 9703535215 SOCIAL SERVICES 1002
RFP-Fit-03007
Attached A
Date ofMeetin g( )s 2/�p3
with Social Services Division Supervisor, t
Comments by SSD Supervisor:
4L4 -L <-
Date
Page 26 of 31
£d 4k160:60 TOW ST 'daS : 'ON Xdd
: 14021d
RFP-FYC-03007 Attached A
Program Category Sexual Abuse Treatment Program Bid Category
Project Title /4a�,-Y�r. SotAe - r p Pr ,'"+ •
Vendor ACie rm orA 4gSoGlrte. ( C .
.
PROJECT DESCRIPTION
Provide a one page brief description of the project.
II. TARGET/ELIGIBILITY POPULATIONS
Provide a one page brief description of the proposed target/eligibility populations. At a minimum
your description must address:
A. Total number of clients to be served.
B. Total individual clients to be served. Please describe if your clients are:
1. Victims under age 18.
2. Perpetrators under age 18.
3. Adult incest perpetrators.
4. Non-abusing spouse
5. Relatives (under 18)in the household of incest victims and/or incest perpetrators.
C. Total family units.
D. Sub-total of individuals who will receive bicultural/bilingual services.
E. Sub-total of individuals who will receive services in South Weld County.
F. Subtotal of individuals who will provide 24-hour access to services.
G. The monthly maximum program capacity.
H. The monthly average capacity.
I. Average stay in the program(weeks).
J. Average hours per week in the program.
III. TYPE OF SERVICES TO BE PROVIDED
Please provide a two-page description of the types of services to be provided. Please address if your
project will provide the service minimums as follows:
A. Comprehensive, diagnostic and treatment planning with the family and other service
providers.
B. Therapeutic intervention with flexibility to bring in other services if needed.
C. Therapeutic services through a variety of modalities including: individual, family, group,
marital, data, etc.
D. Therapy designed to address issues and behaviors related to sexual abuse victimization, sexual
dysfunction, sexual abuse perpetration, and to prevent further sexual abuse.
E. Specialized intake/investigation function for families with sexual abuse allegations.
Also,provide your quantitative measures as they directly relate to each service. At a minimum,
include a number to be served in each service component. Describe your internal process to assure
that FYC resources will not supplant existing and available services in the community e.g. mental
health capitation services,ADAD and professional services otherwise funded.
Page 27 of 31
RFP-FYC-03007 Attached A
IV. MEASURABLE OUTCOMES
Please provide a two-page description of your expected measurable outcomes of the project. Please
address the following measurable outcomes:
A. Reduced rate of recidivism of sexual abuse perpetration within a stated time frame.
B. Decrease in re-victimization.
C. Prevent victim perpetration.
D. A percentage of child abuse incest victims receiving services do not go into placement.
E. Improvement in parental competency as measured by pre and post placement functional test.
F. More rapid reunification of children with families.
Describe your quantitative measures: Also, describe the methods you will use to measure, evaluate,
and monitor each quantitative measure.
V. SERVICE OBJECTIVES
Please provide a one-page description of your expected service objectives and quantitative measures.
Please address, at a minimum, the following ways the project will:
A. Improve Parental Competency- Capacity of parents to maintain sound relationships and
appropriate physical and emotional boundaries with their children, and to empower non-
abusing parents and victims.
B. Improve Family Conflict Management- Mediation and counseling designed to resolve
conflicts and disagreements within the family contributing to child maltreatment and sexual
abuse.
C. Improve Personal and Individual Competencies-Primarily in terms of self-esteem, victim
awareness, awareness and management of one's own personal history of victimization, sex
education,peer relationships enhancement, establishing appropriate physical and emotional
boundaries, assertive in lieu of aggressive behaviors, and assuming responsibility for one's
own behavior.
D. Improve Ability to Access Resources- Services shall assist parent in learning to obtain help
from other sources in the community and within local, state, and federal governments.
Describe the methods you will use to measure, evaluate, and monitor each service objective.
VI. WORKLOAD STANDARDS
Please provide a one-page description of the project's work load standards and quantitative measures.
Please address, at a minimum,the following areas:
A. Number of hours per day,week or month.
B. Number of individuals providing the services.
C. Maximum caseload per worker in the intake function and in the Sexual Abuse Treatment.
D. Modality of treatment
Page 28 of 31
RFP-FYC-03007 Attached A
E. Total number of hours per day/week/month.
F. Total number of individuals providing these services.
G. The maximum caseload per supervisor.
H. The modality of treatment.
I. Insurance.
VII. STAFF QUALIFICATIONS
Please provide a one-page description of staff qualifications and address, at a minimum,the
following:
A. Will your staff, including supervisors,who are providing direct services have the minimum
qualifications in education and experience as defined in Staff Manual Volume VII, Section
7.303.17, and Section 7.000.6,Q, Colorado Department of Human Services. Describe.
B. Total number of staff, including supervisors, available for the project.
C. Is your agency approved by the Sexual Offender Management Board? Explain your
compliance with any mandatory regulating agency.
VIII. Unit of Service Rate Computation
The budget form is to be used to provide detailed explanation of the hourly or daily rate your
organization will charge the Core Services Program for the services offered in this Request for
Proposal. This rate may only be used to bill the Weld County Department of Social Services for
direct, face-to-face services provided to clients referred by the Department. Requests for payment
based on units of service such as telephone calls,no shows, travel time,mileage reimbursement,
preparation, documentation, and other costs not involving direct face-to-face services will not be
honored. Likewise,bills must be for hours or days of direct services to the client,regardless of
the number of staff involved in providing those services. Therefore,it is imperative that this rate
be sufficient to cover all costs associated with this client,regardless of the number of staff
involved in providing these services.
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
receive from the time he or she enters the program until completing the program. On the
manual budget, the only place to put this number is on the Program Budget worksheet. The
computerized budget requires this number to be entered on the Direct Service Cost
Page 29 of 31
PROGRAM BUDGETS
COMPUTERIZED ACTUAL
PROGRAM home based IfT Sexual Abuse Lite skills *Foster Parent'
A TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 20 5 45 30 1
B TOTAL CLIENTS SERVED 120 120 36 120 188
C TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 2,400 600 1,620 3,600 168
D COST PER HOURS OR DAYS OF DIRECT SERVICES(E I C) $48.00 $18.00 $48.00 $46.00 $180.00
E TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $115,200 $28,800 $77,760 $112,800 $30,240
F ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $13,440 $3,360 $9,074 $20,180 $3,528
G OVERHEAD COSTS ALLOCABLE TO PROGRAM $83,380 $15,541 $42,788 $95,040 $15,632
H TOTAL DIRECT,ADMINISTRATION B OVERHEAD COSTS(E+F+G) $192,000 $48,000 $129,622 $288,000 $50,400
I PROFITS CONTRIBUTED BY THIS PROGRAM $0 $0 $0 $0 $0
J TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $182,000 $48,000 $129,622 $268,000 $50,400
K TOTAL HOURS OR DAYS OF DIRECT SERVICE fOR THE YEAR(C) 2,400 600 1,620 3,600 168
L RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE
(J/K) $80.00 $80.00 $80.00 $80.00 $300.00
GROUPS
J
SEE BUDGET JUSTIFICATION SECTIONS OF EACH BID FOR EXPLANATIONS
Ce ' Lion statement
I %��.,� w.�_ declare to the best of my knowledge and belief that the statements
ma this document are true and complete and that the wage rates and other factual unit costs supporting the compensation
paid o to be paid under this contract are accurate, complete and includes no duplicate costs and that I am the CEO or duly authorized agent of
Ackerman and Associates P.C.
Budget justifications to accompany bid worksheet:
The worksheets are based on 2002 income data from Jan 1 2002 through December 31
2002 for Ackerman and Associates P.C. Ackerman and Associates is Category S
Professional Corporation which does not publicly trade stock. As such we will make our
accounting data available to WCDSS services to verify the percentages below upon
written request. Approximate totals can be calculated from data given here.
For 2002 53%of the income of Ackerman and Associates was derived from core services
contracts with WCDSS. 32%was derived from insurance or patient payments, 8%from
mediation and other court related work, 3 %from other contracts and 4% from other
sources.
On the expense side salaries of employees totals 23%of expenses and payments to
provider subcontractors total 56% of expenses making salaries and fees for services
rendered by providers 79 percent of expenses. The proportion of provider fees for
services attributable to core social services payments are 57.5%of the subcontractors'
fees. Our formula for paying providers is based upon 60%of the billed fee for all work
done through Ackerman and Associates. The difference represents uncollected billing
from WCDSS based on individual disputed technical issues and items either closed or
under going review.
The remaining 21%of expenses representing slightly more than $100,000 dollars include
heat light, rent, contract labor other than providers, accounting and insurance costs, legal
services, travel, telephone, advertising, mailing supplies and other costs.
Net profits represented less than one half of one percent of gross earnings in 2002.
Do Payments from WCDSS over or under support Ackerman and Associates?
Taking the total income received by Ackerman and Associates as the base and dividing
this into the income produced by all social services core contract work produces a
multiplier of 0.53. This is to say the 0.53 time expenses not otherwise attributable to a
specific program is used to calculate the appropriate attributable expenses assigned to
WCDSS. Call this amount cost A Adding this number with the actual payment to
subcontractors from WCDSS (Cost B) and assigning .53 times salary costs(cost C)
produces a total amount called D where D is the sum of A+B+C
D represents the total amount of expenses that could justifiably be supported by funds
front social services. An amount E is the total actual payment received from WCDSS for
core services.
The ratio of D divided by E tells us if WCDSS payments supported more or less than its
appropriate share of costs of the overall work of Ackerman and Associates P.C.
L
If D/E is greater than one than more expenses could have been assigned for WCDSS
than money was received from social services, that is to say social services programs
were a potential cost to Ackerman and Associates and fees might be raised. If DIE is less
than one then WCDSS finds are providing additional support for the agency and costs
might be lowered.
For Ackerman and Associates the ratio of D/E is 1.02 for the year 2002 as defined
above. There is no evidence that social services payments are disproportionately
supporting our business activities. Except for a small amount of disputed billing this ratio
would be closer to one.
Ackerman and Associates has never the less elected to reduce or billing fee to $80.00
dollars an hour. All of this reduced cost comes from a voluntary reduction in direct
service fees paid to our providers. While not all providers have elected to join this
voluntary reduction in payment,the majority of those who previously participated in
specific Services programs have elected to do so again. Our overhead costs are relatively
fixed or are expected to rise,. However, given the current crisis in state budgetary issues,
we hope these actions by Ackerman and Associates and its providers will provide needed
service for Weld County's residents and children in need of the services of WCDSS.
Current profit margin for 2002 was less than one half of one percent. WCDSS programs
are not expected to produce profit for us given our fee reduction of 23% at anticipated
rates of services. Note that we are offering considerable treatment capacity. If we
provided services at that capacity, then economies of scale might become apparent but we
consider this scenario unlikely given current budgetary considerations.
Specific additional information byprogram
Sexual abuse—The rate provided on the bid sheet is an individual treatment rate. The
group rate is $40 per participant per group session is contained within the proposal.
Foster parent—The rate provided is a group rate. The unit of service is a two hour group
meeting as defined within the bid. Up to 168 groups will be offered. The expected cost
per participant is less than $20 per hour of group time—less if the group is larger as the
groups are being billed at a fixed rate pr group meeting. The rate for individual services if
requested by WCDSS is $80 per hour.
Home Based, IFT and Life skills—no additional budget information is provided beyond
that contained in the bid as only individual or family services are offered at the same rate.
No group services are offered under these proposals.
LLL
Project Description 2003-2004
Sexual Abuse Family Education and Treatment Program
The SAFE-T Program
Project Description: Ackerman and Associates P.C. proposes to continue to
provide, in 2003-2004, the time limited, outcome focused therapy model for
treatment of the non-offending parent, the victim and siblings of the victim in
sexual abuse cases. Costs to WCDSS have been reduced through a variety of
mechanisms.
The program is proposed in four parts: (each of these parts may be used as part
of an integrated program, may stand alone or be used in combination with other
treatment regimens.)
A. The development of the prescriptive safety education and treatment plan of
the family unit. This will take place over no more than fifteen hours and should
average ten hours.
B. The implementation of the plan with the non-offending parent to increase
safety and avoid repetition of sexual abuse in the family unit. This will take place
over no more than 15 sessions. Up to ten of these sessions would be for
individual treatment. Up to an additional five of these individual session times
could be converted to ten hours of group work. (Throughout the proposal,
whenever we discuss group work, note that it will be billed as one hour of
individual treatment for each two hours of group treatment).
C. Short term treatment for the child who was abused and for the siblings over a
maximum of fifteen sessions to develop skills for future safety and to reestablish
trust, including family issues that need to be addressed with the children. Each
child in treatment, whether that child is the victim or the sibling, should have their
own authorization for treatment. Victim's Assistance may also be of use in
assisting children eligible for part C services. Also offered under part C are
group treatment services for sexually abused children whose own behavior as
potential sexual perpetrators creates a barrier to their family reunification.
D. A protocol of therapy to taper down the frequency of support needed to
provide maintenance of skills developed. This will take place over no more than
ten sessions designed to be delivered on a twice a month basis over a maximum
of five months. This provides an additional support program for those families in
need of the service.
Based on past experience Parts A, B, and C have been used by WCDSS and D
has not been used much. Nevertheless, we submit it here as an appropriate
program for potential future use.
r
•
Any family who is not appropriate to continue in the treatment model due to
severity will be transferred back to Social Services. Determination of progress in
the program will occur at the following review points:
Program Review point#1: A report of recommendations for treatment will be
completed at the end of part A. It will specify 1. The goals to be achieved in part
B and part C, if authorized. 2. What other types of treatment or intervention are
appropriate and 3. If no other intervention is recommended.
Program review point#2: A report of the summary of treatment as the completion
of the treatment plan in part B and part C. The purpose of this report is to answer
these questions.
1. How much progress has been made to date in relation to the treatment
plan?
2. Is it probable the family will complete the treatment in part B or part C
within the session limits specified and if not what other services might be
needed.
This will also be the time point that a determination will be made as to if there is a
need for an extension of sessions in phase B and C and if so why this is needed.
An extension, if needed, will be limited to twelve sessions. Such an extension
can occur only though a second authorization.
The criteria for making judgments as to the family's progress will be based upon
their completion of the prescriptive treatment plan and the adequacy of that
treatment plan to protect the child and family from repeat offenses in relation to
sexual abuse. Families not making progress will be discussed with the
caseworker and as needed referred to other programs.
Please note: the end point of all of the above discussed treatment is not
necessarily intended to be the full and complete resolution of all psychodynamic
issues precipitated by the sexual abuse event. Psychodynamic issues will likely
continue to emerge as the child enters different stages of development into
adulthood. If further funds are needed for full and complete restoration of mental
health (beyond that required for family safety)these funds should be obtained
from the perpetrator and or through victim's assistance and other funds. The
purpose of this program is to recommend to WCDDS if the incident of the actual
abuse has been resolved sufficiently to provide for the ongoing physical and
mental health and safety of the non-offending parent, the child victim and siblings
at the time of discharge from the program.
The purpose of this highly structured system is to assist family members to
achieve careful implementation of safety and child protection plans. Through role
modeling, psychoeducational group and individual work with adults, through child
2.
therapy in individual and on a group basis, families will progress along a
structured treatment course. Treatment will move from recognition of the factors
that lead to the sexual abuse in their particular case to developing and effective
plan to eliminate the resurfacing of these factors and repetition of these types of
events in the future.
Of the four phases of the program, Part A would be limited to 15 sessions
delivered over no longer than three months. Part B and C would be limited to
fifteen sessions each delivered either separately or concurrently over four
months. The step down phase of the program Part D would be limited to no more
than 10 sessions over four to six months. Reviews for the need to continue in the
program would occur in month one, month three and month five.
Families will need the sexual abuse family education and treatment program (the
SAFE-Treatment Program) because the sexual abuse and its implications have
either 1. Imminently placed the children at risk of outplacement from the non
offending parent or parents, 2 created a need to be reunified or 3. The family is
facing imminent reunification failure or 4.The family has failed to implement the
behaviors required of them. Our model does not treat the adult offender. Where
that offender is the parent (usually the father or step father) and reunification is
the agreed upon course of action desired. We would only assist the parties in
developing a formal reunification plan after the offender has completed treatment
in another program and then only in those cases we accept based upon out
clinical judgment.
Our model is expected to work best with younger children and younger teens. It
is expected to be especially useful where the non offending parent is herself a
victim of sexual or physical abuse in her home of origin, or who has a highly
disrupted home of origin from other causes. The program will provide continuity
for the non offending parent and the children through each family having a
coordinator within Ackerman and Associates. That coordinator will also
coordinate the case and be the contact for the case worker and lead the clinical
team on the family. The coordinator will also track the goals of treatment and
organize the aspects of treatment within our clinical team approach. Clinical
teams will discuss each case as necessary.
Purpose; The purpose of the time limited, outcome (safety)focused (as opposed
to psychodynamically focused) therapy is to implement the changes needed to
insure future safety from further sexual abuse. The model assumes a clinical
team oriented family systems approach of education and treatment and seeks
clearly defined behaviors and outcomes that will insure safety. The role of the
non offending parent in the sexual abuse will be explored, looking for points
where protection can be strengthened in the future. The life experiences of abuse
or neglect of the non-offending parent in the home of origin will be a part of the
psychoeducational work that will be necessary by many of the families.
3
In order to develop a treatment plan for addressing the sexual abuse that has
brought the family into social services, the first part of the model will be the
development of the psychological scope of work that will need to be completed.
What are the goals needed to insure future safety? This will be developed
through a review of the case, psychological testing if indicated, and assessment
of the victim and of the victim's siblings. From there, clearly defined, achievable,
structured behavioral changes that are needed to insure future safety of the child
will be developed into a written plan. Once the document is signed by the
therapist and non-offending parent, then this plan will become the treatment
goals for the family in relation to the safety of the child.
Time lines and work to be achieved by phase are listed below:
Part A: The development of the prescriptive treatment plan of the family unit over
no more than fifteen sessions with a goal of the program for prescriptive
assessment to average ten sessions. The prescriptive treatment plan typically
involves interviews with the non-offending parent (up to five hours) three hours of
case review, three hours of assessment and interpretation and up to four hours
of assessment of other family members.
Part B: The implementation of the plan with the non-offending parent to assure
the safety and avoidance of repetition of sexual abuse in the family unit over no
more than 15 sessions. It is anticipated that ten hours of these 15 sessions can
be through group work (at a cost equivalent of five individual hour long sessions)
For the non offending parent a mentoring of psychoeducational process of
identifying factors that contributed to the abuse and dealing with these factors will
be explored. This will be particularly important if negligence or home of origin
issues are present. We postulate that a large percentage of the non-offending
parents will either have been themselves sexual abuse victims or have come
from significantly dysfunctional backgrounds. Such a psychological history would
be amenable to this mentoring approach.
Part C: For the child victim or sibling, the restoration of trust and safety
assurance after the abuse incident itself would be a goal of child treatment. If
appropriate and if the offending parent has successfully completed treatment and
if the victim and the non-offending parent are appropriate for reunification, steps
toward reunification may progress in selected cases.
Group services for sexual abuse victims with potential for sexual acting out:
When children have been sexually abused, some of those children show
potential as they develop into teens to become sexual perpetrators themselves.
Where this tendency is identified as a potential barrier for the reunification or
foster placement of older children, Ackerman and Associates will make available
a group process begun last year through WCDSS request. Treatment of these
children in a group setting has been requested as a useful tool to accelerate
If
reunification safely. This group process is the only service added to this proposal
compared to the previous year.
Part D: A step down protocol of therapy for no more than ten sessions designed
to be delivered on no more than a twice a month basis for supportive transition
from the support program, for those families in need of this service.
Other Considerations:
There is no risk of the program running costs up to levels beyond those budgeted
for any one family because we set a treatment cap for social services funds at a
maximum number of sessions, 15 for part A, 15 for part B, 15 per child for part C.
Our experience has been that sections A, B and C have been used and D is not
used often. Limitations on service delivery allow only 12 additional hours to be
provided in part D. If significant resolution cannot be achieved to assure the
safety of the child within 45 hours of competent psychological treatment, other
options should be considered to attain that safety. In our opinion it will be very
rare for a case to go on for a lengthy period and then fail, as the family will need
to make progress sufficient at each review point to continue in the process.
Rates have been reduced by 23% from the prior year.
Target/Eligibility Populations
Total number of clients to be served in this twelve month program has been
calculated as follows. Three families per month times twelve months equals thirty
six families per year. If we assume a nuclear family size of five, two adults and
three children, then the total client pool to be served is 180 individuals. If we
subtract from the five family members the one offending parent the total becomes
144 individuals. As a minimum, there will be up to 36 non-offending parents and
36 victim children to be served. We expect the need to be lower than this number
and anticipate 18-24 families in treatment over a one year period. We calculated
the budget based on one child in treatment in part C, thus each child in treatment
in part C will need an individual referral.
Distribution of clients. Total number of clients we will serve is approximately 36
index children or more as calculated above. Our experience suggests that for the
family we would expect approximately 36 additional of these would be adult
members of the family (the non offending parent) and approximately 72
additional siblings who would be minors.
Families Served. We would anticipate serving 36 family units or less. We expect
18-24 families is a more likely use rate.
Sub total who will receive bicultural/bilinoual services. We have two
Hispanic members of the staff, Evelin Gomez Ph.D., L.P.C. and Emily Jaramillo
M.A., L.P.C. who both speak Spanish. One of the facilitator's (Joyce Shohet
5
Ackerman) doctoral work was on Hispanic patient's mental health treatment
patterns compared to Anglo patients in Weld County. She also has four years of
direct cross cultural experience with an American Indian population. All of the
staff has cross cultural experience. We expect 50% of referrals can receive
services in Spanish and 100% will receive services in a culturally appropriate
manner. We have been able to and will continue to provide bilingual services for
any family who needs them.
Accessibility. On weekdays all providers of Ackerman and Associates are
accessible through 24 hour answering service and pager system. On weekends,
the 24 hour access reaches the provider on call all of whom are Ackerman and
Associates' licensed mental health providers described in the staff section of this
proposal.
Maximum per month. The program maximum is three new families per month
with a maximum ability to carry eight open cases a month.
The monthly average capacity is two new families per month with the average
load of five open cases a month.
The average stay in the program is outlined for each part of the program. If all
parts of the program are used stay is expected to be 40 sessions over a six
month period. The maximum stay is 45 sessions over a twelve month period
assuming one child in part c with parts A and B also being used. Use of part D
would add 10 hours to this total. A group treatment session would be provided at
a rate of one half of the rate for individual sessions so that each group session
treatment would be at the half the rate of one hour of individual treatment. ($40
per child per group) There are a number of options WCDSS can use to decrease
the cost of this program. For example if assessment is complete prior to referral
then part A might be omitted. Part D costs have been less than projected over
the several years of this project. Nevertheless, we have tried to make best
estimates for the average length of stay in our budget.
Types of Services Provided
The types of services have been described in detail above under project
description and purpose sections. They are summarized here.
We propose to provide a maximum of 55 sessions of outcome focused treatment
over four program subtypes (A,B,C or D) for the victim of sexual abuse, his or her
siblings and the non offending parent. Part A offers assessment of the non
offending parent and the children in terms of treatment needed and if they would
benefit from this program (15 session maximum). Part B is for treatment of the
non offending parent(15 sessions maximum) to improve safety of the child in the
future, Part C is to treat the child victim (15 sessions maximum) of the abuse and
the siblings to improve safety and to establish short term treatment goals for
I.
safety as well as to develop a long term treatment plan. Part D is a transition of
up to 10 sessions for maintenance of achieved skill in those families requiring
this service.
Measurable Outcomes
Measurable outcomes are of two varieties. One type is termed formative
outcomes and the other type is called summative outcomes. Formative outcomes
measure how the program is proceeding while the treatment takes place.
Summative outcomes are the results of the treatment.
In terms of formative measures we have the following...
Family cooperation with appointments and process of treatment in parts A, B C
or D form components of the formative review. Did the family cooperate in
treatment is a primary formative measure.
This data will be extracted from the case file.
Summative Outcomes
A. To reduce the rate of recidivism of sexual perpetration. This
program does not treat sexual perpetrators so at one level this
question does not directly apply. However the goal of the program is
to prevent 100% of revictimizations by treating the victim and the non-
offending parent to alter the family environment and opportunities for
revictimization.
B. Decrease In revictimization should be substantial and persistent. The
program is set up to empower the non-offending parent to identify
situations where victimization is likely and to reduce these
occurrences. We set a goal of 90% of families who complete treatment
will not be victimized in the next two years. This number assumes that
after treatment is completed that the non-offending parent does not
reenter a marital relationship with the offending parent. We set a goal
at 50% at two years post treatment would avoid revictimization if
marital reunification occurs with the offending parent occurs in the next
year.
C. Prevention of victim perpetration. For those victims who complete
part C treatment most will be children who are not sexually active. We
expect that for a two year period following treatment victim perpetration
will be rare and that 90% of children will not be perpetrators over a two
year period following end of treatment. Comments on individual case
risk will be made in final reports. For group work with older children
who have been sexual abuse victims to prevent them becoming sexual
perpetrators a goal of 80% not engaging in inappropriate sexual acting
7
out for the one year period after treatment is set. Comments on
individual risk will be communicated to the caseworker when the child
is discharged from the group process.
D. We expect that 70% of non-offending parents will complete
treatment. Of these we expect that 90%will be able to keep their
children over the next two years if they do not reenter a marital
relationship with the perpetrator.
E. Improvement in parental competency: Parameters measured in this
area include acceptance of the sexual abuse and the need for
restructuring the family environment as well as the client's ability to
achieve that goal to prevent such abuse from occurring again. Clinical
improvement in this area is the goal of the Part B treatment program
and for each client will be reported at the end of treatment.
F. While we do not expect more rapid reunification with all biological
family members (especially the offending parent), we do expect the
acquisition of life skills in anger management and an increase in
psychoeducational knowledge by the non-offending parent. These
should lead to risk reduction for a return to an abusive environment.
Quantitative measures of these outcomes could be assessed at WCDSS
discretion by chart review at two years post treatment by WCDSS to determine if
new charges had been reported or cases opened. Individuals who leave the
county would be lost to follow up in this mechanism. A more vigorous evaluation
method would be preferred but is not budgeted within this proposal
Service objectives
This proposal meets all the service objectives for the non-offending parent and
the victim. The areas for improvement are documented in the quantitative
measures that will be rated for the non-offending parent at the review points and
at the completion of therapy as listed under the measurable objectives section.
These areas include the required components of improving parental competency,
improving family conflict management, improving family conflict management
improving personal and individual competencies and improving ability and
access resources for the non offending parent.
Work Load Standards
A. The program has a capacity of 5 families per month with an average of 3 per
month. The families will receive an average of 45 hours of service as described
if parts A, B and C are utilized.
S
B. We have 6 providers for this program. They are Karen Bender, M.A., L.P.C.,
Cassie Yackley Psy.D., L.P.C., Emily Jaramillo M.A., L.P.C., Evelin Gomez,
Ph.D., L.P.C. Valerie Larson, M.S.W., L.C.S.W. and Joyce Ackerman, Ed.D.
• Emily Jaramillo, M.A. L.P.C. received her masters in Agency Counseling from
UNC. Prior to joining Ackerman and Associates, P.C., she has 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.
• Evelin Gomez, Ph.D. L.P.C. holds a doctorate in psychology and is fluent in
Spanish. She has worked with adult perpetrators and in alcohol dependency
issues.
• Karen Bender M.A., L.P.C. is completing doctoral studies in Psychology and
specializes in treatment of adults who have been victims of domestic violence
and in the treatment of adults who have suffered sexual abuse.
• Joyce Ackerman Ed.D. Psychologist will function as the clinical supervisor of
the program. She has 20 years of private practice experience and is listed in
the National Register of Health Service Providers in Psychology
• Valerie Larson, M.S.W. is a licensed social worker who has experience in the
residential treatment of sexually abused children.
• Cassie Yackley, Psy.D ,has specialized in family systems approaches to
treatment. She has particular skills in community oriented delivery of services.
All of our staff are highly regarded by the caseworkers based on feedback we
have received from supervisors. The 2 psychologists who complete the staff of
Ackerman and Associates serve as back up and support. They are available on
call to assist them as well as to consult on intervention strategies on an
anonymous case presentation basis. The psychologists are Laurence Kerrigan,
Ph.D., and Susan Bromley, Psy.D. Of the up to 36 families the caseload is
projected at ten families or less with each provider.
D. The modality of treatment is individual or group therapy.
E. Hours/weeks. The maximum number of therapist hours is 55 per family over
six months, or a total for the budget calculation maximum of 4400 per year based
on our projected maximum. Average capacity is expected to be at 30 hours for
purposes of planning only or $2400 per year as an estimate. The hourly fee is
requested at $80.00 as documented in the rate calculation section.
9
F. Staff. There are 8 individual providers supported by two office professionals
in the practice as well as a contracted accountant.
G. Supervisor. This contact would be supervised and clinically managed by
Joyce Shohet Ackerman, Ed.D. who will monitor the project for compliance. The
maximum caseload for the supervisor is five families per month.
H. Insurance. Ackerman and Associates, P.C. carries one million, three million
liability coverage for professional liability on the corporation and its associates
and each associate also carries the same level of coverage individually. In
addition, Ackerman and Associates, P.C. carries a general liability policy related
to accident or injury on our premises through Farmer's Insurance.
Staff Qualifications
A. All staff members exceed the minimum qualifications needed for this project
in both education and experience as described above.
B. Staff available for the project is listed above.
Unit of service rate computation
We have calculated the unit of service rate based on the instructions. We used
2002 data for our agency. details are attached to the budget page
Using overall figures for the agency we arrive at a figure of$80 per contact hour.
Group rates are billed at one half this rate per group. The profit for Ackerman
and Associates for all programs was approximately one half of 1% for the 2002
FY 1/1/02 -12/31/02
The proposed cost is $80 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 of$48 per
contact hour consistent with the goals we set for all contractual relationships for
providers. Rate reductions have been achieved primarily through reductions in
fees by providers as well as some increased efficiencies in the group process.
Budaet Justification
Ackerman and Associates purchases services for accounting through an
independent contractor. No special issues are present related to project audit to
out knowledge. Ackerman and Associates mediation program was audited in a
random audit (conducted by Anderson and Whitney) after its first year of
operation with no deficiencies. Audits of the program have been conducted on a
yearly basis, as required by WCDSS, with no deficiencies noted.
10
Ackerman and Associates, P.C. is a type S professional for profit corporation and
not a 501.c.3. Resumes are on file with WCDSS.
Specific standards of responsibility for the 2003-2004 year have been addressed
in the body of the proposal.
See budget pages for additional discussion.
it
BRANCH B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER
23 A 0004087 04/26/2002 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 JOYCESHOHETACKERMAN
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. 05/01/2002 05/01/2003
3. COVERAGE LIMITS OF LIABILITY PREMIUM
Professional Liability $ 1,000,000 each Incident $3,000,000 aggregate $ 1,713.00
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 for n(s) or endorsement(s).
PLP-2012(06/93), PW-2008(Rev. 10/94),, PLE-8035(09/97), PLE-2167(07/00), POE-8004(05/88) (Ed.*10/93), PLE-2081
Current, PON-2003
•
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-
•
BRANCH B/A PRODUCER NUMBER DATE OF ISSUE - PRIOR CERTIFICATE NUMBER
23 A 0004087 - 03/28/2002 Renewal
PSYCHOLOGISTS PROFESSIONAL LIABILITY
CLAIMS-MADE INSURANCE POLICY
. �r. .
NUTICe 7IIIS IS A Ct*ais 1ADE POLICY,PLEASE HEAD 71E POLICY CAREFULLY
Y
PURCHASING GROUP POUCY NUMBER: 45-0002000
stem DECLARATIONS 1 S1ltwlt:AIEA11n 4JR 2050203
1. Named Insured SUSAN PLOCK BROMLEY
1621 13th Ave
ADDRESS Greeley,CO 80631-5415
Number&Street,Town,County,State&Zip No.) t
2. Policy Period: 12:01 A.M.Standard Time At From: - To:
Location of Designated Premises 04/01/2002 - 04/01/2003
3. COVERAGE UMITS 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 contracts ) _ 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. 04/05/1998
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):
PIP-2012(06/93),PLJ-2008(Rev.10/94),,PLE-8035(09/97),PLE-2167(07/00),POE-8004(05/88)(Ed.10/93),PIE-2081
Current,PON-2003
CHICAGO INSURANCE COMPANY -'
55 E. MONROE STREET,CHICAGO, ILLINOIS 60603
Near Nora)Insurance Brokerage
REPRESENTATIVE: Agent or broker: In.Assodationwith Mist Risk Management Services
Office address: 875 N Michigan Ave
a , Stvi 1900 a ' , ;.
City,State,Zip: Chicago IL 60611-1803
Toil-Free Number, 1. 77 1337.9700
PLP-2012(06/93) - APA-
MEMORANDUMOff' INSU CE Date Issued
11/19/2002
Memorandum Holder This memorandum is issued as a matter
of information only and confers no
ACKERMAN & ASSOCIATES ATTN DONNA 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
1776 West Lakes Parkway Covered Person (Status) Owner
West Des Moines, Iowa 50398 EMILY L JARAMILLO—BANSBERG MA
Employee
This is to certify that the Certificate listed below has been issued to the insured named herein for the policy
period indicated, notwithstanding any requirement, term or condition of any contract or other document with
respect to which this memorandum may be issued or may pertain, the insurance afforded by the Certificate
described herein is subject to all the terms, exclusions and conditions of such Certificate. The limits shown
may have been reduced by paid claims.
Certificate
Type of Insurance Number Effective Date Expiration Date Limits
Professional Liability each incident 1,000,000
or occurrence
Occurrence 80M-4003488 11/01/2002 11/01/2003 3,000,000
in the aggregate
General Liability orcoccurl incident
Occurrence in the aggregate
Should the above described Certificate be canceled Insured
oefore 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 JARAMILLO-BANSBERG MA
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:
.d A e Aa•
Account Number: CO KERL 1750 Date: 1/24/03 Initials: GRETCHEN
CERTIFICATE OF INSURANCE
EXECUTIVE RISK SPECIALTY 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:
LAURENCE P. KERRIGAN,
PH.D.
1750 25TH AVE.
SUITE #101
GREELEY, CO 80634
Type of Work Covered: PROFESSIONAL PSYCHOLOGIST
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 008-1766682 12/01/02 12/01/03 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: LAURENCE P. KERRIGAN,
PH.D.
Address: 1750 25TH AVE.
SUITE #101
GREELEY, CO 80634 Au orized Representative
•
Issue Date: 01/11/02
��� The Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
��Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust,Inc.
5999 Stevenson Avenue ACA ws't
Policy Number: CL13187602 Administered by: Alexandria,VA 223043300 TRUST
Toll Free:1-800-347.8847 x284
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Evelin D. Gomez
2. ADDRESS:
16593 East Alabama Place
Aurora, CO 80017
3. POLICY PERIOD: From: 01/16/02 To: 01/16/03
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY S 136 . 00
B. GENERAL LIABILITY S 0 . 00
TOTAL PREMIUM: S 136 . 00
5. LIMITS OF LIABILITY: $100, 000 each Incident or each Occurrence $100, 000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl. Individual) Partnership
Corporation X Other(refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: Employed
(Rating Category) Counselor/Human Development Professional
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and
agreements contained in the following form(s)or endorsement(s): CPL-0004-0199 CPL-0005-0199 CPL-0006.0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005.0199.00
CHANGE ENDORSEMENT - I
THE RECIPROCAL ALLIANCE(RISK RETENTION GROUP)
This endorsement modifies insurance provided under the Professional Liability Occurrence Policy for
Professional Counselors and Human Development Practitioners.
The following spaces preceded by an asterisk%J need not be completed if this endorsement and the policy have the same inception date.
ATTACHED TO AND FORMING 'EFFECTIVE DATE *ISSUED TO:
PART OF POLICY N0. OF ENDORSEMENT
Evelin D. Gomez
CL13187602 11/22/02
A. In consideration of the premium charged:(check appropriate box)
O 1.The name and address under Items 1.and 2.,Named Insured,on the declarations page is
deleted in its entirety and replaced by the following:
® 2.Item 5.,Limits of Liability,on the declarations page is deleted in its entirety and replaced by the following:
$1, 0 0 0, 0 0 0 Each Incident or Each Occurrence $3, 0 0 0, 0 0 0 Aggregate
The premium for this change is included in the premium shown
on the declarations unless a specific amount is shown here. Additional Premium $27 . 00
❑ 3.Coverage and Premium,Item 4 on the declarations page,is deleted in its entirety and replaced by the following:
Coverage Premium
A.Professional Liability
B. In consideration of an 0 additional premium 0 return premium(check appropriate box)of
❑ 1.The policy period,Item 3 on the declarations page,is deleted in its entirety and replaced by the following:
Front To:
12:01 A.M.standard time at the location of the designated premises.
O 2.Coverage B.General Liability is ❑ added ❑ deleted(check appropriate box).
Nothing herein contained shall be held to vary,alter,waive,or extend any of the terms,conditions,provisions.
agreements,or limitations of the above mentioned policy,other
than as above stated.
p E(Lu! ..2. �✓`S , 12/13/02 Authorized Representative Date
CPL•0008.0291 — 2
•
ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY
INSURANCE POLICY DECLARATIONS
Policy Number: PHCP025541 Philadelphia Indemnity Insurance Company
Administered by: CPH &Associates
727 S. Dearborn, Ste. 312
Chicago, IL 60605
Valerie Larson
2500 Haven Court
Evans, CO 80620
Affiliation: AAMFT
Professional Occupation: LCSW
Coverage Term From: (Effective Date)06/27/02 To: (Expiration Date)06/27/03
at 12:01 a.m. Standard Time at the Insured's Mailing Address shown above.
Retroactive Date(if applicable):
COVERAGE A—PROFESSIONAL LIABILITY COVERAGE LIMITS OF PREMIUM
LIABILITY
Individual—Each Incident: $1,000,000 $98.25
Aggregate: $5,000,000
Association, Partnership or Corporation—Each Incident: N/A
Aggregate: N/A
COVERAGE B—SUPPLEMENTAL LIABILITY COVERAGE
Each Incident:: $1,000,000
Aggregate: $5,000,000
COVERAGE C-NON-OWNED AUTOMOBILE (optional)
Each Occurrence:
Aggregate:
Premium (including taxes): $98.25
Policy Forms & Endorsements:
PHCP-01(03/01)
(1 PH
Authorized Signature
Call the Administrator to Verify Claims History at 1-800475-1911
•
Issue Date: 09/21/01
�<N The Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
���Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA huunnn Trust.Inc.
5999 Stevenson Avenue
Policy Number: CL12494601 Administered by: Alexandria,VA 22304.3300 T
Tar leer.1.8O .347.8847 x284 -.S`""'
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Cathleen Yackley
2. ADDRESS:
2911 12th Road
Greeley, CO 80634
•
3. POLICY PERIOD: From: 09/05/01 To: 09/05/02
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY $ 387 . 00
B. GENERAL LIABILITY $ 0 .00
TOTAL PREMIUM: $ 387 .00
5. LIMITS OF LIABILITY: $1, 000, 000 each Incident or each Occurrence $3, 000, 000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl.Individual) Partnership
Corporation X Other(refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: Self-Employed
(Rating Category) Counselor/Human Development Professional
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and
agreements contained in the following forms)or endorsement(s): CPL-0004.0199 CPL-0005.0199 CPL-0006-0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005-0199-00
• Issue Date: 11/26/2002
e Reciprocal' PROFESSIONAL LIABILITY OCCURRENCE
�����Th Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust, Inc. ; ,
Policy Number: Administered by: 5999 Stevenson Avenue TILL
Alexandria,VA 22304-3300
CL10073403 Toll Free: 1-800-347-6647 x284
ITEM DECLARATIONS RENEWAL CERTIFICATE NUMBER 100734 INDIVIDUAL POLICY
1. NAMED INSURED: Norma Karen Bender
2. ADDRESS: 1001 43rd Avenue#41
Greeley, CO 80634-2405
3. POLICY PERIOD: From 2/4/2003 To: 2/4/2004
12:01 A.M. Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific
premium charge or charges
COVERAGE PREMIUM
X PROFESSIONAL LIABILITY $296.40
- GENERAL LIABILITY $0.00
TOTAL PREMIUM: $296.40
5. LIMITS OF LIABILITY: $1,000,000 each Incident or each Occurrence
$3,000,000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl. Individual) — Partnership
— Corporation X Other(Refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: COUNSELOR 0 Full Time
(Rating Category) II Part Time Part Time(21 -30)
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,
stipulations and agreements contained in the following form(s)or endorsement(s):
CPL-0015-0102-00 CPL-0004-0197-00 CPL-0006-0102.00 CPL-0005-0197.00
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT
BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE
INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
CPL-005R-1201-00
03/12/2003 11:19 9783536134 PA B2
TRUQ INSURANCE EXCHANGE
NOME ��OF
OFFICE:1000 W�HRERSOL�ANGELES,,CROUP CAALIFORNIA500010
POLICY DECLARATIONS
1. RETAIL SERVICE - PREMIER
Named • DR JOYCE SHOHETACICERMAN PC
Insured • EasyPay Acct No. Prod.Count
wimp . 1750 25TH AVE STE 101
,' GRESLEY CO 80631 07-04-362 04576-38-07
Address Agent No. Policy Number
The named insured is an Individual unless othmwise stated:
❑Pa p ❑Corporation ❑Joint Venture ❑Organization (Any other)
Type of Business DOCTOR`S OFFICE
2. Policy Period from 07/01/02 (not prior to time applied for) to 07/01/03 12:01 a.m.Standard Time
If this policy replaces other coverage that ends at noon standard time of the same day this 1
until the other coverage ends. This milky will teatime for sums:dye policy policy begins, this policy elect not take effect
Insurance,we will renew this policy if you pay the required renewal sae p follows: oIf subject e tour premiums,
this
rules and fame then in effect premium for each successive policy period to our premiums,
S. Insured location same as mailing address unless ottieiwlee stated:
4.YVe provide Insurance only for those coverages described below and for which a specific limit of insurance is shown.
PROPERTY
COVERAGES AND LIMITS OF INSURANCE
COVERAGES PREN NO. 001 001
BUSINESS PERSONAL PROPERTY 054,080
AUTOMATIC BUILDING INCREASE
PROPERTY DEDUCTIBLE $500
GLASS DEDUCTIBLE 0100
TENANTS EXTERIOR GLASS INCLUDED
OUTDOOR TREES SHRUBS, PLANTS 02,500
FINE ARTS COVERAGE $2,000
ADDITIONAL MURRAIN'S
COVERAGE All Premises
•
WIW1 7-02 ,\
CSN1.1 PAGE 1 OF E
r
Att h.(o:9our,poIicyiwlth the same numbershowmon,this:endorsement r . E4"' O8
• 2nd Edition
- Named Insured• DR JOYCE SHOUT ACKERMAN•PC - • Agent Policy Number
Address• 1750 25TH AVE SOITE 101
07-04-362 04576-38-07
GREELEY CO 80631
• of the Company
designated in the
Declarations
Insured
Location
(Same as above unless o henaise staled here) - - • - -
Effective Date 07/31/96 . Limit of Liability.$ 1,000,000 each occurrence
$ 1,000,000 Annual Aggregate
ADDITIONALINSURED ENDORSEMENT
(SPECIAL SENTINEL) •
In consideration of the premium we agree with you to the following:
1. The insurance provided by this policy for bodily injury liability and property damage liability under Coverage -
D—Business Liability insurance will also apply to the additional insured named below, but only with respect
to an occurrence arising out of the ownership, maintenance or use of that part of the Insured location
occupied by you. -
2. This insurance does not apply to:
(a) Any occurrence which takes place after you cease to occupy the insured location.
(b) Any structural alterations, new construction or demolition operations performed by or for any additional
insured named below.
3. The additional insurecl.will not be construed or deemed to be a subscriber to the Company issuing this policy.
•
•
4. The additional insured will not be or become liable for any premium payments due upon this policy.
5. If this policy i§ terminated for any reason we will give 30 (THIRTY) days notice
in writing to the additional insured named below.
•
This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise
subject to all other terms of the policy.
•
STATE OF COLORADO
Additional
C/O WELD COUNTY SOCIAL SERVICES DEPT •
Insured
ATTN: JUDY GRIECO
PO BOX A
• GREELEY CO 80632 Countersigned
Authorized Representative •
��. (AMR,
'fort Mfg
91.1103 2ND EDITION 6.99 1501 K-95 1501 � 1L
03/12/2003 11:19 9703536134 PAGE 03
COVERAGE EXTENSIONS - Optional HI her Limits of insurance Per Occurrence
CWEtAGE All Promba
ACCOUNTS RECEIVABLE
VALUABLE PAPERS $ 5,000
25,000
OFF PREMISES PERSONAL PROPERTY 8$
85,000
.OPTIONAL COVERAGES: We provide insurance for those Optional Coverages described below.
COVERAGE An Promise
OUTDOOR SIGNS !7,500
EMPLOYEE DISHONESTY $10,000 $500 DEDUCTIBLE
MONET AND SECURITIES 810,000
1500 DEDUCTIBLE
LIABILITY AND MEDICAL PAYMENTS - Except for Fire Legal Liability, each paid claim for the following
coverage reduces the amount of Insurance we provide during the applicable annual period. Please refer to
Paragraph 0.4. of the Liability Coverage Form.
COVERAGE
mans OF INSUMNCE
LIABILITY 81,000,000
MEDICAL EXPENSES $5,000 PER PERSON
TENANTS LIABILITY $75,000 PER OCCURRENCE
•
No. Mc''tpeoe Holder Name Address
N•
•
•
•
ca.
•
weed G /r/02. By
(n/
RCPreselltaeVe)
WIN MO
CISTL! PAC! 1 OF f
03/12/2003 11:19 9703536134 PAGE 04
Polity Number 04576-38-07 Effective Date: 07/01/02
Policy Pains and Endasements attached at inception:
83452-ED1 8P00021299 BP00060197 8P00090197 BP04170t96
BP04340197 BP04390196 BP04550197 E6036-ED1 E0207-ED1
E3342-ED1 25-2110 25-2614 IL01690498 IL02280498
IL02290187 E4009-ED2 8P05110102 BP05130102 25-2880
BP04070187 BP12030689 E6306-ED1 E8162-ED4 E7123-ED1
E3020-ED1 Countersigned g halt L DP 44211
(we, (Autliumat Repmeetda0ve,
Sal 740
REMEM PAGE f Of I
03/122/2003 11:19 9703536134 PAGE 05
TRUCK INSURANCE EXCHANGE
MEMHOME OFFFIC:E:S�THE
FARMERS INSURANCEt,LOS EA6ROUP�ES.OF CALIFORNIA 80010
COMMON POLICY DECLARATIONS
RETAIL SERVICE - PREMIER
1' DR JOYCE SHOHETACKERMAN PC
Named •
insured
In - 1750 25TH AVE STE 101 EasyPay Acct.No. Prod.Count
n9 •
Address • GREELEY CO 80631 07-04-362 04576-38-07
Agent No. Policy Number
The named Insured is an Individual unless otherwise stated:
Q Partnership M Corporation 0 Joint Venture Ci 0rgan®ton (Any other)
T e of Business DOCTOR'S OFFICE
2. Policy Period from 07/01/02 (not prior to time applied for) to 07/01/03 12:01 a.m. Standard Time
N this policy replaces other coverage that ends at noon standard lime of the same day this policy begins, this policy will not take effect
until the other coverage ends. This policy will cantles for successive policy periods as foibws: If we elect to continue this
insurance, we will renew this policy B you pay the required renewal premium for each successive policy period subject to our premiums.
rubs and forms then in effect.
THE POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS LISTED BELOW AND FOR WHICH A PREMIUM IS INDICATED. MS
PREMIUM MAY BE SUBJECT TO CHANGE.
Premium After Applicable Discount and Modification
BOSINESSOWNERS POLICY 8771.00
•
TOTAL
SEE INVOICE ATTACHED
Fonts applicable to all Coverage Par&
IL12011185 IL0003049a 56-5166 IL00171198
Countersigned 4/a/n z. By - 1214311 .
(Date) (Authorised Representative)
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 03-CORE-LS-0002
Revision (RFP-FYC-03005)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2003 and Ackerman and Associates P.C.
Ending 05/31/2004 Lifeskills
1750 25`s Avenue, Suite 101
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 Proposal (RFP)
and the Addendum RFP information. The RFP specifies
Home based visitation and mentoring. Program the scope of services and conditions of award. Except
consists of(1)assessment,goal setting, and where it is in conflict with this NOFAA in which case
compiling treatment goals; (2)mentoring to the NOFAA governs,the RFP upon which this award is
achieve treatment goals through home-based based is an integral part of the action.
interactions, and(3)visitation observations,
recommendations and directed teaching to Special conditions
implement changes in visitation setting. 1) Reimbursement for the Unit of Services will be based on
Maximum number of families per month is 10. a designated per family group conference.
Bilingual/bicultural services. 2) The designated rate will be paid for only direct face to
face contact with the child and/or family, as evidenced
Cost Per Unit of Service by client-signed verification form, as specified in the
unit of cost computation.
Hourly Rate Per $80.00 3) Unit of service costs cannot exceed the designated rate
and yearly cost per child and/or family.
Enclosures: 4) Payment will only be remitted on cases open with, and
referrals made by the Weld County Department of Social
X Signed RFP:Exhibit A Services.
Supplemental Narrative to RFP: Exhibit B 5) Requests for payment must be an original submitted to
Recommendation(s) the Weld County Department of Social Services by the
Conditions of Approval end of 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.
Approval • Program Qfficial:
By a
By • Judy A Griego rector Qry
David E. Long, Chair Weld County De ment of Social Services
Board of Weld County Co sioners Date: '1 0-5
Date: 4-a).-7Lf i
EXHIBIT "A"
A
INVITATION TO BID
OFF-SYSTEM BID 02-03 RFP-FYC 03005
DATE:February 19,2003 BID NO: RFP-FYC-03005
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-03005) for:Colorado Family Preservation Act--Life Skills 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 Program 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 Life Skills Program must provide services that
focus on teaching life skills which are designed to improve household management competency, parental
competency, family conflict management and effectively accessing community resources. This program
announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date I'1QrcJ 13� P-0°) ct4.kee I cqb.
(After receipt of order) BID MUST BE SIGNED IN INIC
cNkxice N .1r..0. mar, t.4%,
TYPED OR PRINTED SIGNATtRE
VENDOR i4CA a r/I\AA ANA 4SSOrAtift I c Slo-s.-• vst-i—c(4%
(Name) Han wri Signature By Authorized
I [[�� Officer or Agent of Vender
ADDRESS f 76'o �rk fT VC 144 fe!o/ TITLE ..)1/4..k...f.Liko
rte/, Co . r043y DATE 3 -1 'a- 03
PHONE# )0 3S3 33 )3'
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 32
RFP-FYC-03005 Attached A
LIFE SKILLS PROGRAM BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING
FAMILY PRESERVATION PROGRAM
2002/2003 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2003-2004
OFF-SYSTEM BID 02-03 RFP-FYC-03005
NAME OF AGENCY: AcAe rars&" MgA 14S,f'ec,061-e
ADDRESS: 17X0- ,25 i}nista. S-170 10 1 G r e e/ey Co 8063Y
PHONE: 91 o x-13 153 -33 7 3 ILO. /
CONTACT PERSON: Ice 4c. erma. . TITLE: i�I JyCs4 /0faIS T '
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Life Skills Program Category must provide
services that focus on teaching life skills designed to facilitate implementation of the case plan by improving household
management competency,parental competency,family conflict management,effectively accessing community resources,and
encouraging goal setting and pro-social values.
12-Month approximate Project Dates: _ 12-month contract with actual rime lines of:
Start June 1.2003 Start
End May 31.2004 4/ End
TITLE OF PROJECT: 4�Ent," A Skin( nit at"
AMOUNT REQUESTED:ur tv r 0 00
lo,. oke rout.. I)4.4 again- Qt a^ X. O
Toyce 1c.Aer►hµ FAA. %. .a.area.--- cial),.
3/m/ 03 . -
Name and Signature of Person Preparing Do Date
Judy A. Griego,Director
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 2002-
2003 to Program Fund year 2003-2004.
Indicate No Change from FY 2002-2003 to 2003-2004
Project Description &ew li 1 t AR A,.
Target/Eligibility Populations
r/ Types of services Provided
,/Measurable Outcomes
_J Service Objectives
r/ Workload Standards
/ Staff Qualifications
Unit of Service Rate Computation
_L Program Capacity per Month 4✓
7 Certificate oflnsurance
/ Assurance Statement
Page 26 of 32
RFP-FYC-03005 Attached A
Date of Meeting(s)with Social Services Division Supervisor: �/d/AD 3
Comments by SSD Superviso -.
7'11x7
Flo
•
•
a/'a//o _
Name and Signature of SSD Supervisor Date
Page 27 of 32
RFP-FYC-03005 Attached A
Program Category Life Skills Program Bid Category
Project Title A li-akoa.. Li Pe SA,lls f rr en.
Vendor Atli
-rn.J /}SSou.4U-c
PROJECT DESCRIPTION
Provide a brief one-page description of the project.
II. TARGET/ELIGIBILITY POPULATIONS
Provide a brief one-page description of the proposed target/eligibility populations. At a minimum
your description must address:
A. Total number of clients 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.Address if your project will
provide the service minimums as follows:
A. Mentoring:
Address, at a minimum,the following ways the project will:
1. Teach,model, and coach adaptive strategies;
2. Model and influence parenting practices;
3. Teach relational skills;
4. Teach household management, including prioritizing, finances, cleaning, and leisure
activities;
5. Actively help to establish community connections and resources;
6. Encourage goal setting and pro-social values.
B. Visitation:
Address, at a minimum,the following ways the project will:
1. Monitor parent/child interactions for physical and emotional safety;
2. Document clinical observations;
3. Strategize for teaching and modeling parenting skills;
4. Teach relational skills;
5. Encourage goal setting and pro-social values;
6. Plan structured activities in visitation to help achieve the objectives of the treatment
plan.
Page 28 of 32
RFP-FYC-03005 Attached A
Provide your quantitative measures as they directly relate to each service. At a minimum, include the
number to be served in each service component. Describe your internal process to assure that FYC
resources will not supplant existing 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. Address the
following measurable outcomes:
A. Improvement of household management competency as measured by pre and post assessment
instruments and/or documented observations.
B. Improvement of parental competency as measured by pre and post assessment instruments
and/or documented observations.
C. Parents can independently work with other sources in the community and within the local,
state, and federal governments.
D. Families receiving Life Skills services will remain intact six months after discharge of the
services.
E. Families/participants who complete the Life Skills Services will have improved competency
level or reduced risk on the standardized assessment, such as the risk assessment tool.
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.
Mentoring:
A. Improve Household Management Competency-capacity of parents to provide a safe household
environment for their children through competent household cleaning and maintenance,
budgeting,purchasing, and leisure activities;
B. Improve Parental Competency-capacity of parents to use adaptive strategies,maintain sound
relationships with their children and provide care,nutrition, hygiene, discipline,protection,
instruction, and supervision;
C. Improve Ability to Access Community Connections and Resources-services shall assist
parents to work with other sources in the community and the local, state, and federal
governments;
D. Improve goal setting and pro-social values.
Visitation:
A. Improve parenting skills,parent/child interactions and relational skills for physical and emotional
safety through structured activities in, and documentation of, visitations to achieve the objectives
Page 29 of 32
RFP-FYC-03005 Attached A
of the treatment plan;
B. Improve goal setting and pro-social values.
Describe the methods you will use to measure, evaluate, and monitor each service objective.
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. Number of hours per day,week, or month.
B. Number of individuals providing the services.
C. Maximum caseload per worker.
D. Modality of treatment.
E. Total number of hours per day/week/month.
F. Total number of individuals providing these services.
G. The maximum caseload per supervisor.
H. Insurance.
VII. STAFF QUALIFICATIONS
Provide a one-page description of staff qualifications and address, at a minimum,the following:
A. Will your staff who are providing direct services have the minimum qualifications in
education and experience?Describe.
B. Total number of staff available for the project.
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
Page 30 of 32
PROGRAM BUDGET$ comsvrERizeu Acrual
PROGRAM _ Mme based )FT Sexual Abuse Life Ills 'ter Parent
TOTAL HOURS OR DAYS OF DIRECT SERVICE PER CLIENT 20 5 45 30 1
TOTAL CLIENTS SERVED 120 120 38 120 186
TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR YEAR(A X B) 2,400 600 1,820 3,600 188
COST PER HOURS OR DAYS OF DIRECT SERVICES(El C) $48.00 848.00 546.00 $48.00 5180.00
TOTAL DIRECT SERVICE COSTS FACE-TO-FACE $115,200 528,800 577,780 $172,600 $30,240
ADMINISTRATION COSTS NON-FACE-TO-FACE ALLOCABLE TO PROGRAM $13,440 $3,360 53,074 $20,180 53,528
OVERHEAD COSTS ALLOCABLE TO PROGRAM 563,380 $18,840 $42,788 555,040 518,832
TOTAL DIRECT,ADMINISTRATION B OVERHEAD COSTS(E+F+O) $152,000 548,000 $125,822 5288,000 $50,400
PROFITS CONTRIBUTED BY THIS PROGRAM $0 50 $0 $0 50
TOTAL COSTS AND PROFITS FROM THIS PROGRAM(H +I) $182,000 $48,000 5125,822 5288,000 530,400
TOTAL HOURS OR DAYS OF DIRECT SERVICE FOR THE YEAR(C) 2,400 600 1,620 3,800 188
RATE PER HOURS OR DAYS OF DIRECT,FACE-TO-FACE SERVICE
(J/IQ $80.0) 580.00 $80.00 580.00 5300.00
GROUPS
SEE BUDGET JUSTIFICATION SECTIONS OF EACH BID FOR EXPLANATIONS
Ce ' tion statement
I o+,"5._C\s.,.%-3....r.., declare to the best of my knowledge and belief that the statements
ma this document are true and complete and that the wage rates and other factual unit costs supporting the compensation
paid o to be paid under this contract are accurate, complete and includes no duplicate costs and that I am the CEO or duly authorized agent of
Ackerman and Associates P.C.
Budget justifications to accompany bid worksheet:
The worksheets are based on 2002 income data from Jan 1 2002 through December 31
2002 for Ackerman and Associates P.C. Ackerman and Associates is Category S
Professional Corporation which does not publicly trade stock. As such we will make our
accounting data available to WCDSS services to verify the percentages below upon
written request. Approximate totals can be calculated from data given here.
For 2002 53%of the income of Ackerman and Associates was derived from core services
contracts with WCDSS. 32%was derived from insurance or patient payments, 8%from
mediation and other court related work, 3 %from other contracts and 4%from other
sources.
On the expense side salaries of employees totals 23%of expenses and payments to
provider subcontractors total 56%of expenses making salaries and fees for services
rendered by providers 79 percent of expenses. The proportion of provider fees for
services attributable to core social services payments are 57.5%of the subcontractors'
fees. Our formula for paying providers is based upon 60%of the billed fee for all work
done through Ackerman and Associates. The difference represents uncollected billing
from WCDSS based on individual disputed technical issues and items either closed or
under going review.
The remaining 21%of expenses representing slightly more than $100,000 dollars include
heat light, rent, contract labor other than providers, accounting and insurance costs, legal
services, travel, telephone, advertising, mailing supplies and other costs.
Net profits represented less than one half of one percent of gross earnings in 2002.
Do Payments from WCDSS over or under support Ackerman and Associates?
Taking the total income received by Ackerman and Associates as the base and dividing
this into the income produced by all social services core contract work produces a
multiplier of 0.53. This is to say the 0.53 time expenses not otherwise attributable to a
specific program is used to calculate the appropriate attributable expenses assigned to
WCDSS. Call this amount cost A Adding this number with the actual payment to
subcontractors from WCDSS (Cost B) and assigning .53 times salary costs (cost C)
produces a total amount called D where D is the sum of A+B+C
D represents the total amount of expenses that could justifiably be supported by funds
from social services. An amount E is the total actual payment received from WCDSS for
core services.
The ratio of D divided by E tells us if WCDSS payments supported more or less than its
appropriate share of costs of the overall work of Ackerman and Associates P.C.
lI
If D/E is greater than one than more expenses could have been assigned for WCDSS
than money was received from social services, that is to say social services programs
were a potential cost to Ackerman and Associates and fees might be raised. If D/E is less
than one then WCDSS funds are providing additional support for the agency and costs
might be lowered.
For Ackerman and Associates the ratio of D/E is 1.02 for the year 2002 as defined
above. There is no evidence that social services payments are disproportionately
supporting our business activities. Except for a small amount of disputed billing this ratio
would be closer to one.
Ackerman and Associates has never the less elected to reduce or billing fee to $80.00
dollars an hour. All of this reduced cost comes from a voluntary reduction in direct
service fees paid to our providers. While not all providers have elected to join this
voluntary reduction in payment,the majority of those who previously participated in
specific Services programs have elected to do so again. Our overhead costs are relatively
fixed or are expected to rise,. However, given the current crisis in state budgetary issues,
we hope these actions by Ackerman and Associates and its providers will provide needed
service for Weld County's residents and children in need of the services of WCDSS.
Current profit margin for 2002 was less than one half of one percent. WCDSS programs
are not expected to produce profit for us given our fee reduction of 23%at anticipated
rates of services. Note that we are offering considerable treatment capacity. If we
provided services at that capacity, then economies of scale might become apparent but we
consider this scenario unlikely given current budgetary considerations.
Specific additional information by program
Sexual abuse—The rate provided on the bid sheet is an individual treatment rate. The
group rate is $40 per participant per group session is contained within the proposal.
Foster parent—The rate provided is a group rate. The unit of service is a two hour group
meeting as defined within the bid. Up to 168 groups will be offered. The expected cost
per participant is less than $20 per hour of group time—less if the group is larger as the
groups are being billed at a fixed rate pr group meeting. The rate for individual services if
requested by WCDSS is $80 per hour.
Home Based, IFT and Life skills—no additional budget information is provided beyond
that contained in the bid as only individual or family services are offered at the same rate.
No group services are offered under these proposals.
l L
Project Description, 2003-2004
Life skills mentoring and visitation program
Overview: Ackerman and Associates, P.C. proposes to deliver a life skills
home based visitation and mentoring program for 2003-2004. We have had a
very successful past seven years of operation delivering a variety of programs
for core services clients through WCDSS. This proposal combines a number
of our successful programs and 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. However, it is
envisioned that the life skills eligible families may be more amenable, based
upon caseworker and supervisor assessment, to a directed learning approach
as opposed to others who need more intensive treatment to avoid placement
or be reunified with their children. As such, the life skills activities consist of
the following activities:
Part one:
Assessment, goal setting and compiling
a set of written treatment goals. Total five hours
Part two:
Mentoring to achieve the treatment goals through home based
interactions. Up to fifteen hours
Part three
Visitation observations, recommendations for parental change and
directed teaching to implement those changes in a visitation setting.
Up to ten hours
These short term solution focused services are designed to help maintain
placement at home or to help reunification succeed and to produce lasting
change in parental interactions to avoid future return into WCDSS services pool.
Strategies are included in this proposal to time limit the delivery of services to an
initial assessment and feedback followed by up to twenty five hours of directed
learning services. The mentoring portion of the directed learning services are
focused on the treatment goals that are derived from the initial assessment and
the caseworkers plan for the family as documented in the referral. The visitation
portion of the delivered services derives from observations of parent child
interactions and the creation of a directed learning program for the parent to
modify observed behaviors to improve interaction with the index child.
Entry into the second and third part of the program would involve construction of
very clearly defined and measurable goals for the family to achieve during the
program. Such goal construction would be completed and accepted by the client
by the end of the fifth hour of contact.
Purpose: We propose to provide life skills services in Weld County usually in the
client's home. These services:
1. Produce a detailed treatment plan during the first five hours of contact,
2. Provide mentoring services to parents whose children are at risk of
imminent placement or whose behaviors prevent reunification. These
mentoring services derive from the assessment and treatment plan
created in part one. Activities are to consist of: teaching, modeling
and coaching to influence parental and adaptive strategies, teaching
relational skills especially age appropriate child parent expectations
and activities, interpersonal, listening and child rearing skills, teaching
household management including setting goals and achieving them for
prioritizing finances, cleaning and leisure activities, actively helping the
parent access needed community connections, learning how to gain
access to resources and encouraging early goal setting and socially
appropriate values.
3. Provide observation and mentoring at visitation services in our offices,
a supervised visit location or in parent's home. We are not proposing to
offer visitation services on routine basis to assure physical and
emotional safety, though we will provide that service when we are the
only professionals supervising the visit. Our primary activity in this
format, because all providers are licensed mental health professionals,
will be in documenting clinical observations, to create a plan for the
teaching and modeling of parenting skills based upon observed and
reported areas of difficulty, and to proactively plan future activities to
help the parent learn appropriate relational and parenting skills specific
to their personal needs. In this way, either through our agency or
through other agencies WCDSS can use the plans created. Overall,
the program will help parents set appropriate and socially proactive
goals for themselves and for their interactions with their children.
Donlan: The strength of this proposal rests upon the experience and expertise of
the staff of Ackerman and Associates.
The strength of our staff in this project, in experience, in bilingual/bicultural
service delivery and in the prior delivery of home-based services and goal
directed short term therapy services for WCDSS clients to over several hundred
client families are considerations we think are important for the reviewers of this
proposal.
2.
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.
Dr. Evelin Gomez, Ph.D., licensed professional counselor holds a masters and
doctoral degree in counseling and is bilingual in Spanish, which is her first
language. She also adds clinical supervisory expertise in drug and alcohol
treatment issues to the Ackerman and Associates professional breadth of
experience.
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.
Cassie Yackley, Psy.D., L.P.C. completed her doctoral studies in psychology and
has been a home based provider during the past two years. She brings expertise
in community oriented psychology to the home based project.
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.
The skill sets necessary to implement parts one through three described above
are enhanced by the experience levels of this staff.
Each part is designed to stand alone although part one needs to precede either
parts two or three. If WCDSS desired only the visitation component or the
mentoring component either of these could be selected providing a number of
ways to tailor the cost of the program to the needs of the client and the
department. For example, part one only would be five hours of service, part one
and two would be twenty hours of service, part one and three would be fifteen
hours of service and if all parts were required that would total thirty hours of
service.
Target/Eligibility Populations
A. Total number of clients to be served. Ten families per month times twelve
months equal one hundred and twenty families per year. If we assume a family
size of six, two adults and four children, the total client pool to be served is 720
individuals. That number includes at least 120 individuals who face either
imminent out of home placement or who need reunification services.
3
B. Distribution of clients. Total number of clients we will serve is approximately
720 as calculated above. Our experience suggests we would expect
approximately 240 of these to be adult members of the family and approximately
480 to be minors. The age of distribution of the index case children would tend
toward the younger children based on our experience with WCDSS. 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. Mentoring and visitation
needs will be age sensitive.
C. Families Served. We would anticipate serving up to 120 family units.
D. Sub total who will receive bicultural/bilingual services. As stated above,
Emily Jaramillo is a masters level counselor(who is also Hispanic of Mexican
American heritage) who can provide services in Spanish or English. She will
serve up to 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 up to an additional one fourth of the
population referred. This represents a maximum of 60 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 120 families) would be done in a
manner that is sensitive to the culture of origin of the family.
E. 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, M.A. L.P.C., Evelin Gomez,
Ph.D. L.P.C., Joyce Ackerman, Ed.D., Karen Bender, M.S., L,P.C., Valerie
Larson, M.S.W., L.C.S.W., and Cassie Yackley, Psy.D., L.P.C.
F. M• imum per month. The program maximum is ten families accepted into
the program per month.
H. The monthly average capacity is ten families per month.
I. The average stay in the program is defined under the purpose section of
this proposal. It is five hours for part one, fifteen hours for part two and ten
hours for part three.
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.
We are using the following strategies to help families attain desired outcomes:
1. Assessment and evaluative services are provided in the first five
hours. The structure of the evaluation is based upon the referral
criteria provided by WCDSS.
2. Mentoring services derive from the assessment and provide services
similar to those provided by solution focused goal oriented short term
interventions. Techniques to achieve parental redirection include
teaching, modeling appropriate behaviors, and coaching a parent
though a scenario commonly encountered that presents problems for
that parent . For example choices that may endanger a child or
create a situation of potential neglect will serve as opportunities to
develop more socially appropriate behaviors.
3. Teaching relational skills especially age appropriate child parent
expectations and activities, interpersonal, listening and child rearing
skills will be an important component of the mentoring program.
4. Teaching household management including setting goals and
achieving them for prioritizing finances, cleaning and leisure activities
will be an additional area covered under the mentoring program.
5. Access to needed resources is also an area addressed in the life
skills program. This requires actively helping the parent access
needed community connections and teaching how to gain access to
resources.
6. Overall, the process of educational change needs to direct the parent
toward a consistent and self desired pattern of setting appropriate
goals early on as opposed to responding to crisis situations and in
developing behavior patterns which reflect a commitment to social
responsibility in the best interest of the child.
7. Visitation which is our primary activity in this format(because all
providers are licensed mental health professionals), will be in
documenting clinical observations. Our purpose is to create a plan for
the teaching and modeling of parenting skills based upon observed
and reported areas of difficulty. We can share this plan with other life
skills providers or can proceed to implement it if directed to do so by
the caseworker.
8. Based on these visitation observations and recommendations, a plan
for future activities to help the parent learn appropriate relational and
parenting skills specific to their personal needs can be developed by
the caseworker. This would be useful if the need for services
exceeds the time allotted under this funding source for establishing
behavioral changes sufficient to close the active case.
9. 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.
10.The visitation and mentoring portions of the program promote the
development of skills-based intervention to empower the client to
handle family situations without the help of others. Overall, the
program will help parents set appropriate and socially proactive goals
for themselves and for their interactions with their children.
Specific techniques that will be incorporated in the delivery of life skills include:
1. Stress reduction and anger management skills.
2. Communications, problem solving, and negotiation skills to
enhance interpersonal effectiveness and develop relational skills..
3. Practice in hands on parenting skills using a coaching model to
provide feedback, reinforcement, and clarification as to appropriate
child management skills based on reported and observed behaviors..
4. 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.
5. 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.
Types of referral services that may be needed include:
• Drug and Alcohol Services. Referrals to alcohol and drug treatment
programs including Island Grove and Family Recovery Center are available.
G
• 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.
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. Was the family assessment in part one completed?
2. Is the family making progress with the treatment plan for each component
as outlined in the service objectives as requested on the case referral?
3. Has the family followed through with recommendations and referrals
during the course of each part of the life skills program?
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. Improvement in household competency will be measured by clinical
assessment. This will be measured by recording the status of the household at
the outset and the conclusion of services using a checklist and documenting
changes in the monthly report.
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
7
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. Parents can work independently with other sources in the community
and within local state and federal governments. Documentation of the
resource needs of the family and how the family accesses these needed
resources will be made by clinical observation and documented in the monthly
reports.
D. Families receiving life skills treatment will remain intact six months after
discharge from the services. This information can be obtained by checking with
the referring caseworker at Social Services at the six month time point after
conclusion of services.
E Families completing the program will have improved competency level
reduced risk on a standardized assessment. The providers will rate the adult
family member(s) at the time of case closure on a standardized parent child
inventory that measures parental interaction and satisfaction with parenting and
be able to compare this to the same measure taken earlier in the process.
Service Objectives
We have the following service objectives:
Mentoring
A. Improvement of parental competency. The program is specifically
designed to resolve conflicts and teach management skills for parents. 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 and behavioral shortcomings related to child parent interactions.. 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. Activities of daily living care, provision of nutrition, hygiene shelter,
discipline protection instruction and supervision are the context that constitute
parental competency. Life Skills 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
8
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.
B. Improve household safety and management . 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.
C. 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.
D Improved Goal settings and Pro-social values derive as a direct
consequence of service objective A-C above. Setting goals to complete the
learning needed based on an agreement at the outset of the life skills program is
inherently a learning experience in positive goal setting.
Visitation
A. Improve parenting skills through directed learning based upon direct
observations to promote physical and emotional safety. Use of activities
specifically structured as is done by us for child custody and special advocacy
activities will form a basis of creating a detailed treatment plan which will
combine the referred problem set with additional observations made in the
visitation process. By the parent accepting the treatment goals of the life skills
program, the parent commits to a process of goal setting and moves to shift
attitudes to a more socially positive value set.
Workload Standards
A. The program has a capacity of ten families per month with an average of five
families per month. the amount of time per family per week will depend on the
family need but is anticipated to be two to three hours per week. Life skill
enrollment should be completed four to ten weeks after referral depending on
the level of services required.
B. We have four licensed mental health providers for this program who will be
life skills specialists. They are Evelin Gomez, Emily Jaramillo, Valerie Larson,
and Cassie Yackley:
9
• Cassie Yackley, Psy.D, L.P.C., has worked with us in home based
treatment over the last two years. She has family and community based
experience as well in her doctoral internship and thesis research.
• 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.
• Evelin Gomez, Ph.D., L.P.C., has work experience that includes clinical
supervision of drug and alcohol issue counseling at Island Grove
Treatment Center. She has also worked with us over the past year in
home based treatment. She is fluent in Spanish.
• Emily Jaramillo, 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.
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. Karen Bender, M.A., L.P.C. has extensive experience in
treating adults for domestic violence and in the treatment of adults who have
suffered sexual abuse. Dr Ackerman will assist in the parent child interaction and
the formulation of the treatment plan.
C. Of the up to 120 families the caseload is projected at 30 families with each
provider over twelve month period —two or three families per provider per month
D. The modality of treatment is home-based solution focused short term
therapy, directed learning, coaching, modeling and teaching. As well, referral
and support will be offered as described above.
E. Hours/weeks. The total number of therapist hours is 30 maximum per family
or a total for the budget calculation of 3600 hours per year based on our
projected average of 120 families. The hourly fee is requested at $80 as
documented in the rate calculation section.
10
F. Staff. There are four individual providers supported by two office
professionals in the practice. There are also three psychologists and another
licensed professional counselor 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 life skills providers exceed the minimum
qualifications needed for this project in both education and experience as
described above. Resumes are on file with WCDSS.
B. Staff available for the project consists of the four life skills 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. They have professional training
in assisting individuals and families to achieve desired and directed behavioral
change as reflected in their licensure by the state of Colorado.
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.
Unit of service rate computation
We have calculated the unit of service rate based in the instructions. We used
2002 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$80 per contact hour.
The profit for Ackerman and Associates for all programs was less than 1% of
gross revenues in 2002.
Ti
The proposed cost is $80 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 ratio of provider fees to
overhead costs consistent with the goals we set for all contractual relationships
for our providers. Reduction in costs this year reflects a decrease in doctoral
level psychologist participation in this program and a reduction in direct fees
charged to WCDSS by Ackerman and Associates providers.
Budoet 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.
Specific standards of responsibility for the 2003-2004 year have been addressed
in the body of the proposal.
See detailed discussion of budget issues attached to the worksheet for this bid.
Resumes are on file at WCDSS.
BRANCH B/A PRODUCER NUMBER DATE OF ISSUE PRIOR CERTIFICATE NUMBER
23 A 0004087 04/26/2002 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 JOYCESHOHETACKERMAN
750 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 05/01/2002 05/01/2003
3. COVERAGE LIMITS OF LIABILITY PREMIUM
Professional Liability $ 1,000,000 each incident I $3,000,000 aggregate $ 1,713.00
4. BUSINESS OF THE INSURED: PSYCHOLOGY
5. The Named Insured is: _ Sole Proprietor(Including Independent contractors) _ Partnership X Corporation
_ Other.
6. This policy shall only apply to incidents which happen on or after: a)the policy effective date shown on the
Declarations: or b) the effective date of the earliest claims-made policy issued by the Company to which this
policy is a renewal; or c) the date specified in any endorsement hereto. 05/01/1992
7. This policy is made and accepted subject to the printed conditions in this policy together with the provisions, stipulations
and agreements contained in the following form(s) or endorsement(s).
PLP-2012(06/93), PLJ-2008(Rev. 10/94),, PLE-8035(09/97), PLE-2167(07/00), POE-8004(05/88)(Ed.*10/93), PLE-2081
Current, PON-2003
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-
BRANCH B/A PRODUCER NUMBER - DATE OF ISSUE PRIOR CERTIFICATE NUMBER
23 A 0004087 - 03/28/2002 Renewal
PSYCHOLOGISTS PROFESSIONAL LIABILITY
CLAIMS-MADE INSURANCE POLICY
Nance 111S IS A CLAIYSA1ADE POLICY,PLEASE LEAD 71E POLCY CAREFULLY
PURCHASING GROUP POLICY NUMBER: 45-0002000
Item DECLARATIONS Cffl mE pia 45P 2050203
1. Named Insured SOSAN PLOCK BROMLEY
1621 13th Ave
ADDRESS Greeley,CO 80631-5415
Number&Street,Town,County,State&Zip No.)
2. Policy Period: 12:01 A.M.Standard Time At From: ' To:
Location of Designated Premises 04/01/2002 04/01/2003
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 contactors) _ 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:orb)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
ri
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 fonn(s)or endorsement(s).
PLP-2012(06/93),PU-2008(Rev.10/94),,PLE-8035(09/97),PLE-2167(07/00),POE-8004(05/88)(Ed.•10/93),PLE-2081
Current,PON-2003
CHICAGO INSURANCE COMPANY
55 E. MONROE STREET;CHICAGO, ILUNOIS 60603
Near North Insurance Brokerage
REPRESENTATIVE Agent or broker. in Association.with Trust Risk Management Services
Office address: 87 M Michigan Ave
r Std 1900 s
City,State,Zip: Chicago,IL spell-1803
Toll-Free Number. 1-877.637-9700
PLP-2012(06/93) APA-
•
ME. ORA, UM OF SU NCE ; Date Issued
11/19/2002
Memorandum Holder This memorandum is issued as a matter
of information only and confers no
ACKERMAN & ASSOCIATES ATTN DONNA 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
1776 West Lakes Parkway Covered Person (Status) Owner
West Des Moines, Iowa 50398 EMILY L JARAMILLO-BANSBERG MA 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 is subject to all the terms, exclusions and conditions of such Certificate. The limits shown
may have been reduced by paid claims.
Certificate
Type of Insurance Number Effective Date Expiration Date Limits
Professional Liability each incident 1,000,000
or occurrence
Occurrence 80M-4003488 11/01/2002 11/01/2003 3,000,000
in the aggregate
General Liability each incident
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 JARAMILLO-BANSBERG MA
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:
.d .�A e >r
Account• Number: CO KERL 1750 Date: 1/24/03 Initials : GRETCHEN
CERTIFICATE OF INSURANCE
EXECUTIVE RISK SPECIALTY 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:
LAURENCE P. KERRIGAN,
PH.D.
1750 25TH AVE.
SUITE #101
GREELEY, CO 80634
Type of Work Covered: PROFESSIONAL PSYCHOLOGIST
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 008-1766682 12/01/02 12/01/03 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: LAURENCE P. KERRIGAN,
PH.D.
Address: 1750 25TH AVE.
SUITE #101
GREELEY, CO 80634 Au orized Representative
Issue Date: 01/11/02
<� The Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
> a INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust,Inc.
5999 Stevenson Avenue Acn usyr:`
Policy Number: CL13187602 Administered by: Alexandria,VA 22304-3300 TRiT T
To Free:1 800347.66471284
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Evelin D. Gomez
2. ADDRESS:
16593 East Alabama Place
Aurora, CO 80017
3. POLICY PERIOD: From: 01/16/02 To: 01/16/03
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY $ 136 . 00
B. GENERAL LIABILITY $ 0 . 00
TOTAL PREMIUM: $ 136 . 00
5. LIMITS OF LIABILITY: $100, 000 each Incident or each Occurrence $10 0, 000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl. Individual) Partnership
Corporation X Other(refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: Employed
(Rating Category) Counselor/Human Development Professional
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and
agreements contained in the following form(s)or endorsement(s): CPL-0004.0199 CPL•0005.0199 CPL•0006.0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005-0199.00
CHANGE ENDORSEMENT - I
THE RECIPROCAL ALLIANCE(RISK RETENTION GROUP)
This endorsement modifies insurance provided under the Professional Liability Occurrence Policy for
Professional Counselors and Human Development Practitioners.
The following spaces preceded by an asterisk(`l need not be completed if this endorsement and the policy have the same inception date.
ATTACHED TO AND FORMING 'EFFECTIVE DATE 'ISSUED TO:
PART OF POLICY NO. OF ENDORSEMENT
Evelin D. Gomez
CL13187602 11/22/02
A. In consideration of the premium charged:(check appropriate box)
❑ 1.The name and address under Items 1.and 2.,Named Insured,on the declarations page is
deleted in its entirety and replaced by the following:
• 2.Item 5.,Limits of Liability,on the declarations page is deleted in its entirety and replaced by the following:
$1, 00 0, 0 0 0 Each Incident or Each Occurrence $3, 000, 000 Aggregate
The premium for this change is included in the premium shown
on the declarations unless a specific amount is shown here. Additional Premium $27. 00
❑ 3.Coverage and Premium,Item 4 on the declarations page,is deleted in its entirety and replaced by the following:
Coverage Premium
A.Professional Liability
B. In consideration of an 0 additional premium ❑ return premium(check appropriate box)of
❑ 1.The policy period,Item 3 on the declarations page,is deleted in its entirety and replaced by the following:
From: To:
12:01 A.M.standard time at the location of the designated premises.
❑ 2.Coverage B.General Liability is 0 added ❑ deleted(check appropriate box).
Nothing herein contained shall be held to vary,alter,waive,or extend any of the terms,conditions,provisions.
agreements,or limitations of the above mentioned policy,other than as above stated.
eta 2. 7141.4.,, 12/13/02
Authorized Representative Date
CPL-0000.0297 - 2
•
ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY
INSURANCE POLICY DECLARATIONS
Policy Number: PHCP025541 Philadelphia Indemnity Insurance Company
Administered by: CPH&Associates
727 S. Dearborn, Ste. 312
Chicago, IL 60605
Valerie Larson
2500 Haven Court
Evans, CO 80620
Affiliation: AAMFT
Professional Occupation: LCSW
Coverage Term From: (Effective Date)06/27/02 To: (Expiration Date)06/27/03
at 12:01 a.m. Standard Time at the Insured's Mailing Address shown above.
Retroactive Date (if applicable):
COVERAGE A—PROFESSIONAL LIABILITY COVERAGE LIMITS OF PREMIUM
LIABILITY
Individual—Each Incident: $1,000,000 $98.25
Aggregate: $5,000,000
Association, Partnership or Corporation—Each Incident: N/A
Aggregate: N/A
COVERAGE B—SUPPLEMENTAL LIABILITY COVERAGE
Each Incident:: $1,000,000
Aggregate: $5,000,000
COVERAGE C-NON-OWNED AUTOMOBILE (optional)
Each Occurrence:
Aggregate:
Premium (including taxes): $98.25
Policy Forms &Endorsements:
PHCP-01(03/01)
ip PPP
l
Authorized Signature
Call the Administrator to Verify Claims History at 1-800-875-1911
•
Issue Date: 09/21/01
�`N The Reciprocal PROFESSIONAL LIABILITY OCCURRENCE
���Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Imu.ea Trot,Inc
5999 Stevenson Avenue .eau
Policy Number: CL12494601 Administered by: Alexandria VA 22304-3300 T
Tel Free:1-80034749847 x284
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Cathleen Yackley
2. ADDRESS:
2911 12th Road
Greeley, CO 80634
3. POLICY PERIOD: From: 09/05/01 To: 09/05/02
12:01 A.M.Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific premium charge or charges:
COVERAGE PREMIUM
A. PROFESSIONAL LIABILITY $ 387 . 00
B. GENERAL LIABILITY $ 0 .00
TOTAL PREMIUM: $ 387 . 00
5. LIMITS OF LIABILITY: $1, 000, 000 each Incident or each Occurrence $3, 000, 000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl.Individual) Partnership
Corporation X Other(refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: Self-Employed
(Rating Category) Counselor/Human Development Professional
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,stipulations and
agreements contained in the following form(s)or endorsement(s): CPL-0004.0199 CPL-0005.0199 CPL-0006-0199
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE
INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE
FOR YOUR RISK RETENTION GROUP.
CPL-0005.0199.00
• Issue Date: 11/26/2002
��� The Reciprocal" PROFESSIONAL LIABILITY OCCURRENCE
��Alliance INSURANCE POLICY FOR
Risk Retention Group PROFESSIONAL COUNSELORS AND HUMAN
DEVELOPMENT PRACTITIONERS
ACA Insurance Trust, Inc. ;
Policy Number: Administered by: 5999 Stevenson Avenue Ak
TRUST
Alexandria,VA 22304-3300
CL10073403 Toll Free: 1-800-347-6647 x284
ITEM DECLARATIONS RENEWAL CERTIFICATE NUMBER 100734 INDIVIDUAL POLICY
1. NAMED INSURED: Norma Karen Bender
2. ADDRESS: 1001 43rd Avenue#41
Greeley, CO 80634-2405
3. POLICY PERIOD: From 2/4/2003 To: 2/4/2004
12:01 A.M. Standard Time at Location of Designated Premises
4. The insurance afforded is only with respect to such of the following types of insurance as indicated by specific
premium charge or charges
COVERAGE PREMIUM
)--L PROFESSIONAL LIABILITY $296.40
- GENERAL LIABILITY $0.00
TOTAL PREMIUM: $296.40
5. LIMITS OF LIABILITY: $1,000,000 each Incident or each Occurrence
$3,000,000 in the Aggregate
6. THE NAMED INSURED IS: Sole Proprietor(incl. Individual) — Partnership
— Corporation X Other(Refer to Item 7 below)
7. BUSINESS OF THE NAMED INSURED: COUNSELOR 0 Full Time
(Rating Category) j Part Time Part Time(21 -30)
8. This policy is made and accepted subject to the printed conditions of this policy together with the provisions,
stipulations and agreements contained in the following form(s)or endorsement(s):
CPL-0015-0102.00 CPL-0004-0197.00 CPL-0006-0102.00 CPL-0005-0197-00
NOTICE
THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT
BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE
INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
CPL-005R-1201-00
03/12/2003 11:19 9703536134 PAGE 02
TRUCE INSLIFIANCE EXCHMANGE
HOME OFFEMBERS OF URE BERSLVDNSURANCE,LOS ANGELES,�FORN��10
POLICY DECLARATIONS
1. RETAIL SERVICE - PREMIER
Named • DR JOYCE SHOHETACKERMAN PC
Insured . EasyPay Aod No. Prod.Count
Nang . 1750 25TH AVE STE 101
Address •
07-04-362 04576-38-07
GREELEY CO 80631 Agent No. Policy Number
The named insured is an bidlvntual unless otherwise stated:
DParinesilp ❑Coryaration DJoint Venture Q Organization (Any other)
Type of Business DOCTOR'S OFFICE
2. Policy Period horn 07/01/02 (not pier to time applied for)to 07/01/03 12:01 a.m.Standard Time
If this policy replaces oiler coverage that ends at noon standard time of the same day this
policy wilt not take effect
until the other coverage ends. Mk piney will continue far successive milky periods ntas fel this
lows: we elect to continue this
Insurance,we will renew this policy if you pay the required renewal premium for each successive policy period subject to our premiums,
rules and forms then In effect,
S. Insured location same as mailing address unless c0erwtee stated:
4.We provide Insurance only for those coverages described below and for which a specific limit of insurance is shown.
PROPERTY
COVERAGES AND LIMITS OF INSURANCE
COVERAGES PREN No. 001 001
BUSINESS PERSONAL PROPERTY $54,080
AUTOMATIC BUILDING INCREASERS
PROPERTY DEDUCTIBLE $500
GLASS DEDUCTIBLE 8100
TENANTS EXTERIOR GLASS INCLUDED
OUTDOOR TREES SHRUBS, PLANTS $2,500
FINE ARTS COVERAGE $2,000
ADDITIONAL OovIRAfn
COVERAGE All Premises
•
„
MAN 7A �• - : '�
gN1en PAGE 1 OF $
:.. .Af�h to'your policy`with the same number:sho'wn on this.endorsement , E4i:Op
•(Named
� 2nd Edition
Insured• DR JOYCE SHOUT ACKERMAN•PC - - Agent Policy Number
Address• 1750 25TH AVE SUITE 101
GHEELEY CO 80631 07-04-362 04576-38-07
• of the Company
designated in the
Declarations •
Insured
Location
(Same as above unless otherwise stated here) ' •
- - -
Effective Date 07/31/96 Limit of Liability $ 1,000,000 each occurrence _ ..
$ 1,000,000 Annual Aggregate
•ADDITIONAL INSURED•ENDORSEMENT
(SPECIAL SENTINEL)
•
In consideration of the premium we agree with you to the following:
1. The insurance provided by this policy for bodily Injury liability and property damage liability under Coverage
D—Business Liability insurance will also apply to the additional insured named below, but only with respect
to an occurrence arising out of the ownership, maintenance or use of that part of the Insured location
occupied by you. •
2. This insurance does not apply to:
(a) Any occurrence which takes place after you cease to occupy the Insured location.
(b) Any structural alterations, new construction or demolition operations performed by or for any additional
insured named below.
3. The additional insurect:will not be construed or deemed to be a subscriber to the Company issuing this policy..
4. The additional insured will not be or become liable for any premium payments due upon this policy.
5. If this policy is terminated for any reason we will give 30 (THIRTY) days notice
in writing to the additional insured named below.
•
•
This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise
•
•
subject to all other terms of the policy.
STATE OF COLORADO
Additional
C/0 WELD COUNTY SOCIAL SERVICES DEPT
Insured
•
ATTN: JUDY GRIECO
PO BOX A
• GREELEY CO 80632 Countersigned
Authorized Representative •
i ,i9e1i{
l �ILTIV
�.ceouq
9'.-1103 IND EDITION 695 1501 K-95 1501 te=[iu
03/12/2003 11:19 9703536134 PAGE 03
COVERAGE EXTENSIONS - Optional Nigher Limits of Insurance Per Occurrence
COVERAGE All Po mbea
ACCOUNTS RECEIVABLE $25,000
VALUABLE PAPERS $25,000
OFF PREMISES PERSONAL PROPERTY $5,000
.OPTIONAL COVERAGES: We provide Insurance for those Optional Coverages described below.
COVERAGE All Remises
OUTDOOR SIGNS *7,500
EMPLOYEE DISHONESTY $10,000 $500 DEDUCTIBLE
MONEY AND SECURITIES *10,000
$500 DEDUCTIBLE
L BILITY AND EDICAL PAYMENTS - t for Fire coverage reduces the amount of Insurance weprovide during l theapplicable annual annual peh paid riod Please for the eerefer to
Paragraph 0,4. of the Liability Coverage Fonn.
COVERAGE mit OF INSURANCE
LIABILITY $1,000,000
MEDICAL EXPENSES $5,000 PER PERSON
TENANTS LIABILITY $75,000 PER OCCURRENCE
KIPS
No. Wean Holder Name, Address
y.
dx
Cowdersigned C /15/02
� IW0 (Au Represents )
arnme PAGE OP
0p/12/2003 11:19 9703536134 PA 84
Policy Numhec 04576-38-07 Elective Bala 07/01/02
Policy films and Endotaemenb attached at inception:
E3452-ED1 BP00021299 8P00060197 BP00090197 BPo41701%
BP04340197 BP04390196 BP04550197 E6036-ED1 E0207-ED1
E3342-ED1 25-2110 25-2614 I1,01690498 I1,02280498
IL02290187 E4009-ED2 BP05110102 BP05130102 25-2880
BP04070187 BP12030689 E6306-ED1 E8162-ED4 E7123-ED1
E3020-ED1
ConnbeWnned . 6 l slo L BY ailsAdolf
(Date) (Authe�lmd Repn!lenfative)
rem 7-0E
WENS PAGE ! or S
03/32/2083 11:19 9703536134 PAGE 05
TRUCK INSURANCE EXCHANGE
HOME MEMBERS THE FR.SHIMREE BLVD., FANG ANGELES,CALIFORNIAOUP OF COMPANIES010
COMMON POLICY DECLARATIONS
RETAIL SERVICE - PREMIER
1' DR JOYCE SHOHETACKERMAH PC
Named •
Insured - 1750 25TH AVE STE 101 Easy ay Acct.No. Prod.Count
Mailing •
Address • GREELEY CO 80631 07-04-362 04S7b-38-07
Agent Na. Policy Number
The named Insured is an individual unless otherwise stated:
C Partnership till Corporation O Joint Venture Q Organization(Any other)
Type of Mims DOCTOR'S OFFICE
2. Policy Period from 07/01/02 (not prior to time applied for)to 07/01/03 12:01 a.m. Standard Time
If until his policy the replaces other image that ends at noon standard time of the same day this policy begins, this policy will not take effect
r coverage ends. This policy will continue Jar successive policy periods as follows: If we elect to continue this
insurance, we win renew this policy If you pay the required renewal premium for each successive policy period subject to our premiums,
rules and forms then in effect
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS LISTED BELOW AND FOR WHICH A PREMIUM IS INDICATED. THIS
PREMIUM MAY BE SUBJECT TO CHANGE.
Premium After Applicable Discount and Modification
BOSINESSONNEgS POLICY 6771.00
•
TOTAL SEE INVOICE ATTACHED
Forms applicable to all Coverage Parts
IL12011185 IL00030498 56-5166 IL00171198
Countersigned tokhL By - SmILE
(orb) I (AuthoddRepresentatve)
slaw sae
COMM Pets 1 d 1
(111-tailitress,s\ DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY,CO. 80632
Website:www.comeld.co.us
Administration and Public Assistance(970)3524551
Child Support(970)352-6933
Wilk MEMORANDUM
COLORADO
TO: David E. Long, Chair Date: April 28, 2003
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services " a li
RE: Notification of Financial Assistance Award OFAA)under Core
Services Funds-Ackerman &Associates, P.C.
Enclosed for Board approval are Notification of Financial Assistance Awards (NOFAA) for Core
Services Funds with Ackerman&Associates,P.C. The Families, Youth and Children
Commission(FYC) has reviewed these proposals under a Request for Proposal process and is
recommending approval of these bids.
The major provisions of the NOFAAs are as follows:
1. The period of each 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. Ackerman& Associates,P.C., agrees to provide services to those children and families
who are in imminent risk of placement under child welfare and as referred by the
Department. The services to be provided through Ackerman&Associates, P.C., are as
follows:
A. Under Option B,Home Based Intensive,this program offers solution-focused
services provided primarily in the home. The maximum hours provided is 20
hours per referral. The services are focused on assessing needs, providing short-
term intervention and assisting the Department with recommendations. The
program maximum is eight families per month with a monthly average capacity
of five families per month. The average stay in the program is three hours per
week over an average of a three-month period(for a maximum of 20 hours).
Bilingual/bicultural and South County services are available. The hourly rate is
$80.
2003-1066
MEMORANDUM
David E. Long, Chair, Board of County Commissioners
NOFAAs—Ackerman&Associates
B. Under Mediation and Facilitation under the Intensive Family Therapy Program
service components include (1) identification of extended family for family
planning meetings, (2)mediation services in a five-hour model, (3) address in
appropriate families a very specific short-term treatment goal that must be
resolved in order to either avoid placement or allow reunification. Services to a
maximum of ten families per month, the average capacity is six families per
month, and the average stay is a maximum of five hours. Bilingual-bicultural and
South County services are available. The hourly rate is $80.
C. Under Sex Abuse Treatment,this program proposes to provide a time-limited,
outcome focused therapy model for treatment of the non-offending parent, the
victim and siblings of the victim in sexual abuse cases.The program is proposed
in four parts: (each of these parts may be used as part of an integrated program,
may stand alone, or be used in combination with other treatment regimens.) The
projected maximum total per year is estimated at 36 families, three families per
month. The average monthly capacity is three families. The maximum stay is 46
sessions over a 12—month period. Group treatment is provided at one-half the
hourly rate. The hourly rate is $80.00.
D. Under Lifeskills, this service provides home-based visitation and mentoring. The
program services consist of(1) assessment, goal setting, and compiling treatment
goals; (2) mentoring to achieve treatment goals through home-based interactions,
and (3)visitation observations, recommendations and directed teaching to
implement changes in the visitation setting. The maximum number of families
per month is ten. Bilingual-bicultural services are available.
If you have any questions,please telephone me at extension 6510.
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