HomeMy WebLinkAbout20011414.tiff RESOLUTION
RE: APPROVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARD FOR THE LITTLER
CENTER - DAY TREATMENT AND AUTHORIZE CHAIR TO SIGN - NORTH RANGE
BEHAVIORAL HEALTH
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Notification of Financial Assistance
Award for The Littler Center- Day Treatment between the County of Weld, State of Colorado,
by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Social Services, and North Range Behavioral Health, commencing June 1, 2001,
and ending May 31, 2002, with further terms and conditions being as stated in said award, and
WHEREAS, after review, the Board deems it advisable to approve said award, a copy of
which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, ex-officio Board of Social Services, that the Notification of Financial
Assistance Award for The Littler Center- Day Treatment between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Social Services, and North Range Behavioral Health, be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said award.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 30th day of May, A.D., 2001.
BOARD OF COUNTY COMMISSIONERS
WELD CO TY, COLORADO
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Weld County Clerk to th o I� t[ ..�`.t'°� .
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Robert D. Masden
2001-1414
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41011 DEPARTMENT OF SOCI
AL SERVICES
PO BOX A
GREELEY,CO 80632
Administration and PublicAssistance(970)352-1551
O Child Support(970)352-6933
COLORADO
• MEMORANDUM
TO: M. J. Geile, Chair
Board of County Commissioners Date: May 23, 2001
FR: Judy Griego, Director• Q _
Weld County Departme of S ial Se ces
RE: PY 2001-2002 Notification of Financial Assistance Awards (NOFAA) under Core
Services Funds-North Range Behavioral Health
Enclosed for Board approval are the PY 2001-2002 Notifications of Financial Assistance
Awards(NOFAA) for Families, Youth, and Children Commission (FYC) Core Services
Funds, which are for the period of June 1, 2001,through May 31, 2002.
The Families, Youth and Children Commission (FYC)reviewed proposal's under a
Request for Proposal process and are recommending approval of these bids.
North Range Behavioral Health Inc
Da Trent: Littler Center,A capacity of 20 children at any given time annually, ages
5-12, 29.5 hours weekly, 5.9 hours per day,for 36-52 weeks. On-site plans(JEP); i.e.,
occupational therapy, speech/language services,physical therapy, Bicultural-bilingual
services. Rate is$1,550/month.
If you have any questions, please telephone me at extension 6510.
of
2001-1414
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 FY01-PAC-2004
Revision (RFP-FYC-01006)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2001 and North Range Behavioral Health
Ending 05/31/2002 The Littler Center-Day Treatment
1306 11th Avenue
Greeley,CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial Assistance
Award is based upon your Request for Proposal(RFP).
A comprehensive, highly structured service The RFP specifies the scope of services and conditions
alternative to the out-of-home placement or the of award. Except where it is in conflict with this
more intensive placement.A capacity of 20 at any NOFAA in which case the NOFAA governs, the RFP
given time, 29.5 hours weekly, an average of 5.9 upon which this award is based is an integral part of the
hours daily, for 36-52 weeks. action.
Cost Per Unit of Service Special conditions
Monthly Rate $ 1550.00 1) Reimbursement for the Unit of Services will be based
Hourly Rate Per $ 13.14 on a monthly rate per child or per family.
Based on Approved Plan 2) The monthly rate will be paid for only direct face to
face contact with the child and/or family, as specified
Enclosures: in the unit of cost computation.
X Signed RFP:Exhibit A 3) Unit of service costs cannot exceed the hourly and
X Supplemental Narrative to RFP: Exhibit B yearly cost per child and/or family.
Recommendation(s) 4) Payment will only be remitted on cases open with, and
X Conditions of Approval referrals made by the Weld County Department of
Social Services.
5) Requests for payment must be an original submitted to
the Weld County Department of Social Services 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.
Approvals: Program Official:
By 4 ALr/ By ' Q
M. J. eile, Chair Judy ' . Gri:_., Dir tor
Board of Weld County Commissioners Weld ounty Department of Social Services
Date: 03-3o- XO1 Date: 571.3/0 I
,QC C)/ /1
Signed RFP: Exhibit A
North Range Behavioral Health
RFP: 01006-Day Treatment
INVITATION TO BID
DATE: February 28, 2001
BID NO: RFP-FYC-01006
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-01006) for:Famil Pr se
Y—��'vation Program Da re n r gFam gamily
s Isues Cash Fun_ d v prese nation Program Fund
Deadline: March 23, 2001, 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 Statewide Family Preservation Program (C.R.S. 26-5.5-101) and
Emergency Assistance for Families with Children at Imminent Risk of Out-of-Home Placement (C.R.S. 26-5.3-
101). The Families, Youth and Children Commission wishes to approve services targeted to run from June 1,
2001, through May 31, 2002, at specific rates for different types of service, the county will authorize approved
vendors and rates for services only. The Day Treatment Program Category must provide a comprehensive, highly
structured program alternative to placement or more restrictive placement that provides therapy and education
for children. This program announcement consists of five parts, as follows:
PART A...Administrative Information
Format
PART B...Background, Overview and Goals PART E.D..Bid r Evaluation onPse Process
PART E...Bid Process
PART C...Statement of Work
Delivery Date
(After receipt of order) BID MUST BE SIGNED IN INK
— Tlale F Peter nn T W T q
TYPED OR PRINTED SIGNATURE
VENDOR North Range Behavioral HP 1 th
(Name) Handwritten Signature By Authorized
Officer or Agent of Vendor
ADDRESS 1306 11th a<,Pn„o
Greeley C0 80631 TITLE Fx c,I01 n;recto__`_
DATE 3-21-01
PHONE # 970-353-3686
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 32
RFP-FYC-01006 Attached A
DAY TREATMENT PROGRAM BID PROPOSAL
FAMILY PRESERVATION PROGRAM
2001/2001 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2001-2002
BID #RFP-FYC-01006
NAME OF AGENCY: North Range Behavioral Health
_ADDRESS: 1306 11th Avenue Greeley,CO 80631
PHONE: ( 970 ) 353-3686 or 352-2201
CONTACT PERSON: Sandee Atwood, MSW,LCSW TITLE: Program Di rector
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Day Treatment Program Category mu,r
provide a comprehensive,highly structured program alternative to placement that provides therapy and education for children
12-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1. 2001 Start
End May 31,2002 End
TITLE OF PROJECT: Kathleen Painter Littler Center
Sandee Atwood, MSW, LCSW A` eee^ 'd eltta 31073)O /
Name and Signature of Person Preparing Document Y11 Date
Dale Peterson, MSW MHA dak„ a3-21_01
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Posposal
for Bid.For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 2000-2001
to Program Fund year 2001-2002.
Indicate No Change from FY 2000-2002
LAProject Description
• & Target/Eligibility Populations
Types of services Provided 7C
6O Measurable Outcomes
-Sat Service Objectives X
Workload Standards x
c"%ik Staff Qualifications a(
Unit of Service Rate Computation X (cost of living increase)
Program Capacity per Month
Certificate of Insurance
Page 26 of 32
RFP-FYC-01006 Attached A
Date of Meeting(s)with Social Services Division Supervisor: 3 /2 T/
Comn ents qy SSD Supervi�sI: /____L E -9,.:01-(-( h;m b c,Y- c CO C(4 �� c r ifs)_
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Page 27 of 32
I. PROJECT DESCRIPTION
In August 1995, Weld County School District Six (District 6), the University of Northern Colorado (UNC), and
North Range Behavioral Health (NRBH)jointly opened the Carson Children's Center (CCC). In August 1999
the CCC became the Kathleen Painter Littler Center. Littler is a year around residential and day treatment
program for children ages five through 13 years. It has capacity of 20 students.
Day treatment is a comprehensive, highly structured alternative to the out-of-home placement or the more
intensive placement of a child already in placement that provides mental health care and education to its
student clients. Treatment services for each client's family are an integral part of the program. The Littler
Center provides highly integrated and coordinated educational and treatment services to its students. The
affective needs of each child are responded to not only by the treatment staff, but by the educational and
supportive services staff as well. Similarly, the students' education and emotional and behavioral needs are
not solely the responsibility of the teaching staff but shared by all on-site personnel. Because all Littler
students are staffed as special needs children, additional services called for in each child's individualized
education plans (JEP) such as occupational therapy, speech/language services, and physical therapy are
provided on-site.
The Littler day begins with a welcoming group to greet the children and to help them make the transition
from life at home to a day in school and in treatment. Information from each student's parents, guardians, or
foster parents is obtained directly or via notebooks sent home with and brought back each day by the
students to keep the staff and parents/guardians up-to-date and to encourage open communication. Each
child's goals and progress toward them are updated daily before the children move to other aspects of the
day. Educational and affective curricula are simultaneously in place as much as is feasible in the various
daily activities. The students progress through a series of treatment and educational offerings each day.
While some children are in the classroom for group or individual instruction, others are seen in individual
therapy while others are in a treatment group. Each day treatment student is assigned a master level
therapist who not only assists in developing individualized treatment plans, but also serves as an on-going
consultant and treatment coordinator to all school staff. There are ongoing, scheduled therapeutic groups
that address new themes as well as themes from earlier sessions. These groups address social skills,
conflict resolution, self-esteem, and positive relation building as well as how to handle feelings. The daily
schedule is similar from day to day promoting the consistent milieu essential to the children's success.
Recess, lunch, and other activities are similarly integrated. The day ends back in the room where welcomes
occurred. Now, the focus is to review the day with the children and prepare them for the transition back to
their homes. Goals and successes of the day are the foci of this activity. Children may remain for a family
therapy session. Family therapy typically is planned for the end of the day to allow for parents' work
schedules. The schedule is sufficiently flexible to allow for such sessions during the school day as well.
Individual and family therapy continues to occur during school breaks, depending on the availability of the
clients.
Psychiatric services are integrated in the program. Each child receives a psychiatric evaluation including a
determination of need for psychotropic medications. Follow-up psychiatric services are provided throughout
each student's stay and, when appropriate, in the care that follows treatment at Littler.
Students with special treatment needs have available to them the full array of services of NRBH in addition
to those available at Littler. Students can be seen in groups designed to help them deal with sexual abuse
and other trauma they have endured.
II. TARGET/ELIGIBILITY POPULATIONS
It is intended that the Littler Center serve up to 20 children ages five through 12 years and their families at
any given time in the 6 to 18 month day treatment program. Of these, it is anticipated that up to ten could
have the financial aspect of their care covered under the services proposed herein. Up to 18 children and
their families will be served annually of whom 12 will possibly be eligible for FYC-funded services. It is
anticipated that approximately 25% of all the students and/or their families will receive some level of
bilingual/bicultural services on-site. Based on current utilization rates, it is estimated that up to 25% of the
Littler students will be from southern Weld County. For the purposes of this grant, the monthly maximum
program capacity is defined as 10 children with a monthly average program capacity of eight. The average
length of stay in the program is estimated to be in the range of 36 to 52 weeks. Students spend a minimum
of 29.5 hours weekly in the total program. In order for a child to be considered as a potential student of the
Littler Center, she or he must be staffed into special education services in her or his home school district
and must have demonstrated the capacity to return to her or his home school upon successful completion of
the Littler program. In addition, the student must have a full scale IQ of 76 to benefit from the Littler Center
program levels and expectations.
Children referred to the project will have met, or be at high risk to meet, the out-of-home placement criteria
detailed in the request for proposal. As mentioned above, each will also have met or be believed to qualify
for special education services.
III. TYPE OF SERVICES TO BE PROVIDED
Site-based services to the students of the Littler Center and their families will be held each day District 6
schools are regularly in session plus through the summer. An academic year will consist of 46 total weeks
with an average of not less than 29.5 hours of programming weekly, 5.9 average daily hours.
The planning and implementation of the Littler Center has been a collaborative and cooperative effort from
its inception. The Weld County Department of Social Services (WCDS S), involved early on in the planning
process, agreed to utilize the services of this day treatment program for those of its clients demonstrating
the need for it and for whom they believe they have financial responsibility. The Littler Center's admission
coordinator works to ensure that FYC resources do not supplant other community resources and WCDSS
caseworkers are involved prior to the screening process for all WCDSS children. The collaborative role of
Weld County School District 6 has been exemplary from the planning stage forward as it furnished the past
site, recruited and hired professional and paraprofessional staff, and provided administrative guidance.
Similarly, NRBH, with the strong support of its Board of Directors and management team, offered
administrative assistance in planning and implementing the treatment program.
Extensive effort has been invested into planning the milieu and overall program of the Littler Center so that
educational, therapeutic, behavioral, and recreational components are closely integrated. By design, each of
these four components contains aspects of the other three. Concerted efforts helped to achieve and now
serve to maintain this high level of integration. The educational component is primarily the responsibility of
the District 6 teaching staff plus other instructional staff as may be required. The therapeutic component is
primarily the responsibility of the NRBH on-site staff.The behavioral component of the Littler Center is
present across all activities of the program and is the responsibility of all on-site personnel. Each student
has an individualized education plan and a mental health services/treatment plan that spell out educational,
behavioral, and emotional concerns and detail how those concerns will be addressed in the daily activities
of the student. Similarly, the recreational component of the Littler Center includes educational, therapeutic,
and behavioral programming to meet each student's needs. All components of the program are typically
carried out on-site. Exceptions to this occur primarily during times when a student is in a transitional stage in
returning to her or his home school and when off-site services, such as involvement in a particular therapy
group not offered on-site, are indicated.
Beginning at intake and throughout the program, parents, guardians, and other caretakers are actively
encouraged to engage in their children's education and treatment. Family therapy sessions are held at least
weekly for each student. In most instances, parental or guardian involvement is mandatory. This stems from
a core belief that not just the child, but also his or her family must actively involve themselves in the
treatment/education process for it to be effective and for the positive results to be longstanding. The mental
health services plan dictates the specific nature of the family work that is required for each child.
The teachers at the Littler Center are certified special education teacher for significantly identifiable
emotionally disturbed children. They are assisted by three full-time, specially trained paraprofessionals in
carrying out each student's individualized educational plan. Due to age of the Littler students, there has
been no need for vocational or independent living assessment or training to date.
Each student receives an initial mental health assessment. The therapist, parents/guardians, caseworker, if
appropriate, and psychiatrist work to establish a behaviorally specific service plan that details individual
therapy, family therapy, psychiatric needs, and case management needs. The service plan identifies the
specific outcomes necessary for the child to be successful at a lower level of care. It is the tool by which
progress is measured. Typically each student weekly receives at least one individual therapy session, five
sessions of therapeutic or psycho-educational group activities, and one session of family therapy.
This can very based on the needs of the specific child and their family. More frequent services may be
provided during the initial stages of treatment or during a time of crisis. Fewer services maybe provided
during the latter stages of treatment when a child is transitioning back to their home school. Those students
with psychotropic medication needs are the responsibility of the Littler staff psychiatrist, Wallace LaBaw,
MD. There is simultaneous development or updating of the individualized education plan when a child is
staffed into the Littler Center.
The physical health needs of Littler students including, but not limited to nutrition, medical, and dental, are
primarily the responsibility of District 6 nursing staff. These are shared as appropriate by the staff of the
Littler Center.
Proactive planning for reintegrating a student into her or his home school begins during the initial screening
of the child for consideration of admission to Littler. The capacity to return to one's home school, i.e., the
school referring the child, or the school the child will be returning to, will depend upon promotion to her or
his next higher grade, must be established before a child will be accepted into the Littler program as must
be the referring school's willingness to have the student return there.
Similarly, the graduation requirements for students admitted to the Littler Center are formulated in a
preliminary manner during the screening and planning sessions held with each child and her or his family,
the staff of the referring school, and social services caseworkers when appropriate. The requirements are
largely expressed in terms of outcomes the child will achieve. The program is constructed to emphasize the
positive outcomes and gains each student will make. Whenever possible, the strengths of the child will be
used as the primary tools for progress.
Follow-up mental health care for students graduating from the Littler will be arranged by the Littler Center's
mental health staff with NRBH, other mental health centers, or a private practitioner of the graduate's
family's or guardian's choosing. The transition plan that guides the student's return to her or his own school
also provides for a stepped, systematic introduction to the new therapist or reintroduction to a previous
therapist to ensure continuity from day treatment to more traditional outpatient services.
IV. MEASURABLE OUTCOMES
At the time of admission to the Littler Center, each student will be evaluated using, in part, the Colorado
Clinical Assessment Report (CCAR) developed by the Colorado Office of Mental Health Services. Every six
months thereafter and at discharge from the Littler Center the CCAR will again be administered. The three-
page form covers a wide range of variables and assessments. The Littler Center Admission and
Termination Evaluation Forms are to be used as evaluation tools as well. These look specifically at the
effects of the littler program. Copies of these forms are attached at the end of this proposal. The therapist
conducts a complete assessment 10 days after enrollment to develop an all inclusive behavior/treatment
plan to meet the student's needs. Discharge goals are developed for all identified areas of need and the
measurable short term goals developed monthly to measure and work toward the discharge goal.
It is anticipated that 90% of the children successfully completing the Littler program will reside in their own
homes, or remain in placement at a similar level of care as they were at the time of their referral, for the first
six months after their discharge. The criteria for success will be that each child returns to or remains in her
or his home or foster home and is able to safely and constructively do so for at least the first six months they
are no longer attending the Littler Center. This information will be gathered by three and six month follow-
ups with the child's family and their WCDSS caseworker, if appropriate.
Additionally, all successful graduates will enter, remain in, and make satisfactory progress in public school
after their discharge from the Littler Center. More specifically, each graduate of Littler will maintain or
enhance the progress she or he made academically, socially, behaviorally, and emotionally during her or his
time in the program. This will be monitored by three and six month follow ups with the child's family, their
WCDSS caseworker, if appropriate, and by the school community facilitator (or the equivalent) from her or
his home school. The criteria for success will be maintenance of or improvement upon her or his levels of
functioning in the four areas mentioned above as stated in their individualized educational plan and their
mental health services plan.
The families of 90% of the children successfully completing the Littler program will report a more relaxed,
nurturing, and competent relationship with their children than existed prior to enrollment. Families will be
surveyed at discharge, three months and at six months after discharge.
Ninety percent of the children completing the Littler program will report and demonstrate an improved sense
of self worth, self-confidence, and decreased high-risk behaviors. Appropriate improvements will be
revealed when pre-C.C.C. CCAR ratings are compared with similar ratings done at the time of completed
transition back to the home school.
V. SERVICE OBJECTIVES
The primary goal of the Littler Center is to successfully intervene in the lives of its students and their families
to minimize the future need for similar intensive services, to enhance each child's ability to be educated and
to benefit from that education in her or his home school, to enhance each child's ability and capacity to
respond appropriately and healthfully to her or his family, and to improve each child's family's abilities to
adequately and appropriately respond to and provide for the child's needs in a competent, safe, nurturing,
And growth enhancing manner.
In working with families to achieve the goal of improving their abilities to manage family conflict in a safe,
constructive manner, the Litter Center staff works toward the objective of resolving conflicts between
parents and children so that no maltreatment of the children occurs, no domestic violence occurs, no
children run away from home, and no children commit status or legal offenses. Success is measured by
family, caseworker, and therapist reports that the objective was met. Each family will also be asked to report
on its subjective improvements in this area.
To meet the Littler Center goal of improving overall parental competency, an objective of increasing the
parents' abilities to develop and maintain sound, caring, effective relationships with each other and with their
children is established. An additional objective is to enhance the abilities of the parents to provide, with as
much proficiency as possible, for their family's care, nutrition, hygiene, discipline, protection, education, and
supervision. All parents are encouraged to develop appropriate support systems designed to last beyond
their child's involvement with the Littler Center. Again, the parents and children will be polled concerning
their subjective opinions about the improvements they have made, as will the therapist and caseworker.
The Littler Center works with each client family to achieve the goal of improving its household management
competency. The objective is to enhance the capacity of the parents to provide a safe household
environment for the children through competently managing the home to include cleaning, repairing, and
maintaining the home, as well as via effective budgeting and purchasing. The family, therapist, and
caseworker will document the improvements made in this area.
The Littler Center works to improve each family's ability to find and use appropriate resources. Treatment
and case management services assist each family to learn more effective means to obtain needed help
from other sources in the community and from local, state, and federal governments. This is modeled in
each of the families' relationships with the Littler staff. The families will report, and their caseworker and
therapist will confirm, all gains made in this area.
VI. WORKLOAD STANDARDS
The Littler Center will provide day treatment services to 20 children aged five through 12 years who will
meet the FYC funding criteria. A year round academic/treatment schedule is in place. It is anticipated that
up to 18 children will be enrolled in the course of a year. The average length of stay in the program will
range from 36 to 52 school weeks. Littler students will attend an average of at least 5.9 hours of
programming daily on all days the school is in session. The total staff of the Littler Center numbers mote
than 17 individuals, comprising slightly more than the equivalent of 13 full-time employees. This staffing
level exceeds all Colorado licensing rules. Said rules specify a student to total staff ratio of not more than
eight to one which is far less than the four to one ratio employed at Littler. If there is a time when only one
staff member is present, a second staff member is on call and immediately available to be summoned to an
emergency. NRBH certificate of insurance coverage is attached.
VII. STAFF QUALIFICATIONS
Licensing requirements mandate that day treatment programs have a treatment leader who is
responsible for the overall mental health services to each child. This person must hold a master's
degree in the behavioral sciences and have not less than three years of clinical experience.
Counselors in day treatment programs are mandated by the State of Colorado to have completed a
bachelor's degree in the behavioral sciences or to have at least four years of experience with
appropriate aged children, and must be at least 21 years of age. All of the staff meet or exceed
these requirements. John Ashby, MSW (soon to be LCSW) with eleven years experience, Matt
Newton, MSW, LCSW with twelve years of experience, Bonnie Derby, MSW, LCSW, with fifteen
years of experience and Sheryl Gonzalez, MS, four years experience.
Sandee Atwood, MSW, LCSW, is the Littler Center Program Director as well as Clinical Director.
Once a child is accepted into the Littler Center the intake coordinator, Cath Stilwell, MSW,
establishes a preliminary treatment plan and then the clinical director works with the primary
therapist in the development of the day treatment plan for each student. Ms. Atwood has fifteen
years experience as a Psychiatric Social Worker in the school system and twelve additional years
as a clinical director for an outpatient treatment center and day treatment center. Three of those
years were as Clinical Director of Devereux Cleo Wallace Treatment Center in Westminster,
Colorado.
Wallace LaBaw, MD, staff psychiatrist for the Littler Center, is a board certified psychiatrist. He is
able to follow-up with children after they graduate from the Littler Center and enter more traditional
outpatient care through NRBH.
Mike Hoover, Ed.D is the administrative supervisor of the Littler Center's educational component.
Since 1992, he has been a Special Education Coordinator for District 6. Currently certified as a
School Psychologist and Special Education Administrator, he has worked in the field for more than
20 years.
The Littler Center's teachers are Gayle Schneider, MA, Gail Gerdes, BA and Cindy Takahashi, BA.
Ms. Schneider is a certified special education teacher for significantly identifiable emotionally
disturbed children and is also certified in the area of learning disabilities and mentally
handicapped. Ms. Gerdes has a BA in Special Education and is a licensed teacher in the State of
Colorado. Ms. Takahashi has completed her requirements in Special Education Affective Needs .
Leigh Ann Luberstedt is the Speech/Language Clinician. She has completed her masters degree in
speech language pathology. Beth Gay is the School Psychologist and does assessments and
conducts IEP team meetings. Ms. Gay has an Ed.S. degree in School Psychology and is a
nationally certified school psychologist. Karen O'connell is a registered occupational therapist and
provides both direct and consultative OT services to the Littler Center. Three full-time
paraprofessionals, Cindy Jones, Freddie Ancheta, and Jennifer Crawford, assist the teachers in
carrying out each student's individualized educational plan.
Ann Teague, an RN and Nurse Practitioner, is the school nurse and health consultant to the C.C.C.
She regularly checks in with the staff and students of the C.C.C. and is also available as needed.
VIII. PROGRAM CAPACITY BY MONTH
The Littler Center is designed to function with a minimum clinical staff contingent of 4.OFTE, serving an
average of 15 - 18 children and their families at any given time.
VIII. PROGRAM CAPACITY BY MONTH
The Littler Center is designed to function with a minimum clinical staff contingent of 4.OFTE, serving an
average of 15 - 18 children and their families at any given time.
RFP-FYC-01006
Attached A
VIII. COMPUTATION OF DIRECT SERVICE RATE
This form is to be used to provide detailed explanation of the hourly 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 for
these services 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, billings must be for hours of direct service 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.
(Explanations for these Lines are Provided on the Following Page)
Total Hours of Direct Service per Client 840
Hours [A]
Total Clients to be Served 18
Clients [B]
Total Hours of Direct Service for Year 15,118
(Line [Al Multiplied by Line [B] Hours [C]
Cost per Hour of Direct Services $ 12.11
Per Hour [D]
Total Direct Service Costs $ 183 150
(Line [Cl Multiplied by Line [D] ) [E1
Administration Costs Allocable to Program $ 5,000
[F]
Overhead Costs Allocable to Program $ 10,500
Total Cost, Direct and Allocated, of Program$ 198.650
Line [E] Plus Line [F] Plus Line [G] ) [H]
Anticipated Profits Contributed by this Program $ -0-
[I]
Total Costs and Profits to be Covered
by this Program(Line [H] Plus Line [I] ) $ 198.650 [J]
Total Hours of Direct Service for Year 15,118
(Must Equal Line [C] ) [R]
Rate per Hour of Direct, Face-to-Face Service
to be Charged to Weld County Department of
Social Services $ 13.14
[L]
Page 31 of 32
RFP-FYC-01006
Attached A
Day Treatment Programs Only:
Direct Service House Per Client Per Month 118
[M]
Monthly Direct Service Rate $ 1,550
[N]
[A] This is an estimate of the total hours of direct, face-to-face service each client will
receive from the time he or she enters the program until completing the program.
[B] This is an estimate of the number of clients who will be served during the period from
June 1, 2001, through May 31, 2002.
[D] This represents the average hourly salary and benefits that your organization pays its
direct service providers plus any costs which are directly attributable to the face-to-
face session with the client.
[F] This represents the salary and benefits of direct service, supervisory, and clerical
personnel which are not incurred in providing direct, face-to-face service to the
client, but can be allocated to this program for time spent on the program for
activities such as travel, phone conversations, "no-shows," discussions with involved
parties, meeting preparation, and report completion.
[G] This represents the Agency Overhead costs, such as Rent, Utilities, Supplies, Postage,
Travel Reimbursement, Telephone Charges, Equipment, and Data Processing which are not
incurred in providing direct, face-to-face service to the client, but can be allocated
to this program for time spent on the program for activities such as travel, phone
conversations, "no-shows," discussions with involved parties, meeting preparation, and
report completion.
[H] This represents the Grand Total Costs directly attributable or allocable to this
program. It should be a reasonable assumption that if you decided to discontinue this
program, your agency would realize a reduction in costs approximately equal to this
amount.
[I] This represents the total amount of profit your firm expects to realize as a result of
operating this program. Any difference between Lines [H] and [J] must be substantiated
by an amount indicated on this line.
[L] This is the actual direct, face-to-face hourly service rate at which you will be
requesting payment for the services provided under the conditions of this Request for
Proposal.
[M] To be completed by prospective providers of the Day Treatment Program only, this line
represents the estimated number of hours per month your organization will provide
direct, face-to-face services per client.
[N] To be completed by prospective providers of the Day Treatment Program services only,
this line represents the actual direct, face-to-face monthly service rate at which you
will be requesting payment for the services provided under the conditions of this
Request for Proposal. Calculated by multiplying Line [L] by Line [M] .
Page 32 of 32
Mar- 21 , 01 08 : 15A P. 01
Client# : 15394 NORRA �J� ��V6(a
A.CQBQ.. CERTIFICATE OF LIABILITY INSURANCE DATE(MIuUDONTI
12/21/00 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION —
Flood & Peterson Ins . Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. O. Box 578 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
4687 W. 18th Street
Greeley, CO 80632 INSURERS AFFORDING COVERAGE
INSURED ,INSURERA Irwin Siegel Agency Inc .
North Range Behavioral Health INSURERe
1306 11th Avenue Ns,RERc
Greeley, CO 80631I N$URF.RD
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHCH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR POUCY EFFECTIVE POLICY EXPIRATION
LTR 'TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDNY1 DATE(MMADON_y) LIMITS
A GENERAL LIAB0.RY 5182327225 01/01/01 01/01/02 FACH OCCUPRENCE .$1 , 000, 000
X CONIMERCIALGENERAL LIABILITY FIRE DAMAGE(Any one ere) $200, 000
CLAIMS MADE X OCCUR MED EXP(Any one parson) s15, 000
PERSONAL 6 ADV INJURY :1, 0 0 0, 0 0 0
GENERAL AGGREGATE s3 , 000, 000
GEN"L AGGREGATE LIMIT APPLIES PER. PRODUCTS •COMP.0P AGG s3, 000, 000
POLICY •PRO-
! PJECT LOC _
A I AUTOMOBILE LIABILITY Si 8 2 3 2 7 2 2 5 01/01/01 0 1/01/0 2 :COMEINED SINGLE LIMIT
X)ANY AUTO '(Ea acclEen11 $1, 000, 000
ALL OWNE0 AUTOS
� BODILY INJURY $
SCHEDULED AUTOS (Per perspnj
X :HIRED AUTOS
BODILY PLJURY $
X NON-OWNED AUTOS IPe.welder!)
PROPERLY DAMAGF $
(Per accicenr)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
'OTHER THAN
AUTO ONLY. AGG S
A EXCESS LIABILITY .S182327225 01/0 1/0 1 ;0 1/0 1/0 2 CACI I OCCURRENCE $
! OCCUR CLAIMS MADE AGGREGATE F
� I
4 b
DEDUCTIBLE $
X RETENTION E _ S_
WORKERS COMPENSATION AND WC SL O
TORY LIMITS I• ERR
TR-
• EMPLOYERS LIABILITY
E.L.EACH ACCIDENT S
E.L.DISEASE•EA EMPLOYEE $
E.L.DISEASE-POLICY LIIAIT
A OTHER Professional 5182327225 01/01/01 .01/01/02 $3 , 000, 000 Aggregate
Liability $1, 000, 000 Per Incident
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESdEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS !�
Project : Little Center
CERTIFICATE HOLDER ADDITIONALINSURED;INSURER LETTER: CANCELLATION
SHOULD ANY OPINE ABOVE DESCRIBED POLICIES RE CANCELLED BEFORE THE EXPIRATION
Weld County Social Services DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 OAY$WRITTEN
315 N. 11th Avenue NOTICE TOTHE CERTIFICATE HOLDER NAMED TOTME LEFT,BUT FAILURE TO 0050 SHALL
Greeley, CO 80631 IM POSE NO OBLIGATION OR LIABILITY OF ANY KING UPON THE INSURE RATS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
r�JO�* Jae?f�i1:Son'L -riiStvJe3rt-C� 1- .
ACORD 25-S(7/9711 of 2 #S179291/M172817 LDM O ACORD CORPORATION 1988
Littler Center
Forms
KATHLEEN P. LITTLER CENTER ADMISSION EVALUATION FORM(8/99)
Client Name Client Id ft
Diagnosis: Primary Secondary
Date of Birth School Grade City
Admit Date Center Admit Littler
Medicaid Yes No(Check One) Sex Ethnicity
Who has custody of child at time of admit to Littler?
Where was child living immediately prior to admission to Littler?
Outpatient Therapist(if any)
Address/Phone
Special Behaviors or Circumstances/Reasons for referral
PAST PRESENT
Yes No Yes No
Suicidal
Violence toward others
Runaway Behavior
Self Mutilating Behavior
Social Isolation
Past Legal Charges
Current Legal Charges
On Probation
Victim Physical Abuse
Victim Sexual Abuse
Alcohol Use
Use of Inhalants
Other Drug Use
Learning Disabilities
Special Education
Others(specify)
GAF SCORE AT ADMISSION
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNTIONING SCORES AT ADMISSION(Rate all six areas.)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
Societal Functioning
Interpersonal Functioning
Daily Living Personal Care
Physical Functioning
Cognitive Intellectual
Overall Level of Functioning
KATHLEEN P. LITTLER CENTER TERMINATION EVALUATION FORM(8/99)
Client Name Client Id#
Littler Discharge Date:
Discharge Diagnosis: Primary Secondary
If psychotropic meds were used, please list below:
1.
2.
3.
Who has custody of child at time of discharge from Littler?
Where will the child be living immediately after discharge from Littler?
Who will follow youth after discharge?
Special Behaviors or Circumstances
PRESENT
Yes No
Suicidal
Violence toward others
Runaway Behavior
Self Mutilating Behavior
Social Isolation
Legal Charges Pending
On Probation
Victim Physical Abuse
Victim Sexual Abuse
Alcohol Use
Use of Inhalants
Other Drug Use
Learning Disabilities
Special Education
Others(specify)
GAF SCORE AT DISCHARGE
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNTIONING SCORES AT ADMISSION(Rate all six areas.)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
Societal Functioning
Interpersonal Functioning
Daily Living Personal Care
Physical Functioning
Cognitive Intellectual
Overall Level of Functioning
COLORADO CLIENT ASSESSMENT RECORD 1 I
NAME: mGAF SCORE
ETHNIC/RACE 74
AGENCY' I I 'PROGRAM 4-5 1)A American Indian/Alaslmn Native
I I I I I I I I I IcuENT ID su (2)AsianIPacific Islander
(3)Black
REFERRING AGY (4)Hispanic
CLIENT ID 1523 (5)White(Non-Hispanic)
(6)Multi-Racial
I I I I I I I I I 'MEDICAID ID 2442 HISPANIC ORIGIN is
ADMISSION DATE au-4o (1)Not of Hispanic Origin
MONTH DAY YEAR (2)man-American(3)Puerto Rican
ACTION TYPE (Manual Input Only) 4142 (4)Cuban
(5)Other Hispanic
01=Admission 11=Correction to Admission MARITAL STATUS n I
02=AdWate 12=Correction to Activation
03=Update 13=CCIRUhah to Update (1)Never Married (4)Widowed
04=Inactivate 14=Correction to Inactivation (2)Married (5)Divorced
05=Discharge 15=Connection to Discharge (3)Married Separated(Legal or Marital Discord)
06=Evaluation Only PLACE OF RESIDENCE 77 I
I MEDS ONLY CLIENT 43 (1)Correctional Facility/Jail
(2)Inpatient
(1)Yes (2)No
(3)Nursing Home
ratADMISSION STATUS 44 (4)Residential Facility-Mental Health
t'c"t_ :n (5)Residential Facility-Non-Mental Health
(1)New Admission (6)Boarding Home
(2)Readmission From This Fiscal Year (7)Homeless-In Shelter
(3)Readmission From Prior Fiscal Year (8)Homeless-On the Street
PERMANENT HANDICAP/IMPAIRMENT 45-43 (9)Other Independent Living Arrangement
(Code 8115 Boxes Using 1 Yes 2 No) CURRENT LIVING ARRANGEMENT n I
(1)Mental Retardation
(1)Lives With Both Parents
(2)Deafness or Severe Hearing Loss
(2)Lives With One Parent
(3)Blindness or Severe Visual Impairment (3)Lives With Spouse and or Other Relative(s)
(4)Speech Impairment (4)Lives Alone
(5)Non-Ambulatory or Assisted Ambulation (5)Lives Wilk Unrelated Person(s)
CURRENT EMPLOYMENT STATUS n I
LEGAL STATUS 30 (1)Employed-Full Time
(1)Voluntary (2)Employed-Part Time
(2)Court-Directed Voluntary (3)Homemaker-Not Otherwise Employed
Forensic Involuntary
S
(4)72-Hour Evaluation and Treatment(MH-HOLD) (5)Not in Labor Force Employment
(5)Shod-Term Certified (6)Unemployed For Less Than 3 Months
(6)Long-Tenn Certified (7)Unemployed For 3 Months or More
(7)Voluntary Hospitalization of Mears (8)Anned Forces(Active Military Duty)
(8)Children'Code C.R.S.19-1-101 ANNUAL FAMILY HOUSEHOLD INCOME eoa4
(9)Emerg/Invoi.Alcoholism/DrugCommitment
VMS{ REFERRAL SOURCE 5142 I I I
PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS 6b87 NUMBER OF PERSONS SUPPORTED BY ss I
lx aPpAae1e) S INCOME(Include Client)
1 1 I I I II I t THI(1)1 (client only) (6)6
I PRESENTING PROBLEM HAS EXISTED se (2)2 (7)7
(1)1 Year or Lager (2)Less Than 1 Year (4)4 (9)8
( ) (9)9 or More
PREVIOUS MENTAL HEALTH SERVICES es-r2 (5)5
(Code ALL Four Boxes Using 1 Yes 2 No) HIGHEST EDUCATION LEVEL-IN YEARS es-n I I
Inpatient Care (Less Than Fiat Grads Code as 00)
Other 24Hour Care
Partial Care DUE TO MENTAL HEALTH REASONS, N
Outpatient Care CLIENT IS CURRENTLY RECEIVING:
(1)SSI (3)Both
I I COUNTY OF RESIDENCE 4344 (2)SSDI (4)Neither
DATE OF BIRTH esn FIRST 3 LETTERS OF CLIENTS LAST NAMEesai I I I
Ken i:ollgtvialtataissi ZIP CODE 9249 97.100
MONTH DAY YEAR -I I I I
&`1 SEX n Triage Denver Health&Medical Center Only not I
(1)Male (2)Female
White—Billing Yellow—Chart SHADED BOXES ARE NOT PROCESSED ON UPDATE Form#255 R 11/97
•
MENTAL HEALTH SERVICES CODE SHEET
AGENCY NUMBER MHASA CODES REFERRAL SOURCE FIRST THREE
15 Adams BH Beh.Health Care,Inc LETTERS OF
11 Arapahoe BH Beh.Health Care,Inc PERSONAL CLIENTS LAST
48 Aurora BH Beh.Health Care,Inc 61 Self NAME
65 BHI Other BH Beh.Health Care,Inc 62 Family/relative
63 Friend/Employer/Clergy
Provide the first three
23 Boulder BR Boulder letters of the client's last
66 Boulder Other BR Boulder MEDICAL/PSYCHIATRIC name. Ignore all blanks
ation.
18 Jefferson JE Jefferson 68 Outpatient psychiatric Service or Clinic and punct
lesu S John
69 Private psychiatrist P
67 Jefferson Other JE Jefferson 70 Other private MH practitioner would be coded STJ.
71 CMHI/P
04 Pikes Peak PI Pikes Peak-Options For clients with only two
72 CMHI/FL letters In their last name,
70 Pikes Peak-Options Other PI Pikes Peak-Options 73 Colorado Mental Health Center/Clinics' code a 2 in the third box.
24 San Luis Valley SY SyCare-O 74 Nursing Home Extended Care Organization Example: The last name
moons 75 Community residential organizations Wu would be coded:
17 Southeast Colorado SY SyCare-Options 76 Alcohol/Drug treatment facility W U 2
51 Spanish Peak SY SyCare-Options
77 Other Physician
14 West Central SY SyCare-Options 78 General hospital inpatient psychiatric program For Clients with only one
71 SyCare Options Other SY SyCare-Options 79 Other inpatient psychiatric organization letter in their last name,
leave the second box
06 Weld WE Weld SOCIAL SERVICE/EDUCATION blank and put a 1 in the
68 Weld Other WE Weld 81 Social service agency third box. Example: Y
82 Agency for the Developmentally Disabled would be coded:
02 Colorado West WS West Slope-Options 83 Vocational rehabilitation facility y 1 1
27 Midwestern Colorado WS West Slope-Options 84 Educational system/school
20 Southwest Colorado WS West Slope-Options 85 Shelter for homeless/abused
72 Western Slope Options Other WS West Slope-Options
LEGAL
90 CMHI at Fort Logan 91 Law enforcement(includes police,sheriff,DA)
80 CMHI at Pueblo 92 Court(includi
ng n9 juvenile)
93 Correctional facility
94 Probation/parole
42 Arapahoe House
05
Asian ALL OTHER REFERRAL SOURCES
07 Centennial 98 Other
53 CHARG
25 Children's XX Referral source not known
54 Community Care
55 Denver Health 8 Medical Center •For both Mental Health Institutes at Pueblo and Fort
12 Larimer Logan-If referral is prescreened by a Colorado
38 MH Corporation of Denver Community
45 Serviclos De La Raze,Inc. Agency,w MHASA,use the agency
number,otherwise use MHASA number.
CATCHMENT AREA OR RESIDENCE BY COUNTY
01 Adams(excluding Aurora) 18 Douglas 35 Larimer 52 Rio Blanco
02 Alanosa 19 Eagle 36 Las Animas 53 Rio Grande
03 Arapahoe(excluding Aurora) 20 Elbert 37 Lincoln 54 Routt
04 Archuleta 21 El Paso 38 Logan 55 Saguache
05 Baca 22 Fremont 39 Mesa 56 San Juan
06 Bent 23 Garfield 40 Mineral 57 San Miguel
07 Boulder 24 Gilpin 41 Moffat 58 Sedgwick
08 Chaffee 25 Grand 42 Montezuma 59 Summit
09 Cheyenne 26 Gunnison 43 Montrose 60 Teller
10 Clear Creek 27 Hinsdale 44 Morgan 61 Washington
11 ConeJos 28 Huerfano 45 Otero 62 Weld
12 Costilla 29 Jackson 46 Ouray 63 Yuma
13 Crowley 30 Jefferson 47 Park 64 Outside Colorado
14 Custer 31 Kowa 48 Phillips 70 Aurora(Adams County)
15 Delta 32 Kit Carson 49 Pitkin 71 Aurora(Arapahoe County)
16 Denver 33 Lake 50 Prowers 72 No Permanent County of
17 Dolores 34 La Plata 51 Pueblo Residence
EFFECTIVE DATE
I. An effective date is not required for a new admission episode. The admission date automatically becomes the effective date.
2. An effective date Is required on all update,activate,inactivate records and correction forms. This date is important when calculating changes to
contract status or leveling criteria.
54247 H:1mM4HHmtelpeayelbolmhodeNetdoc
COLORADO CLIENT ASSESSMENT RECORD 2
Client I.D. Name- Admit Date
HISTORY 1o2-10- Check AU.that Apply CURRENT P-SEV Check ALL Problems that Apply
Vxd:Sexual Abuse Hist:Suicide Attempt _Hist:Unstable Employm AGGRESSIVENESS 191497
Vict:Physical Abuse Hist:Family Ment-III Acting Out Defiant Threatening
—Y1cs:Neglect —Hid:Family Sub-Abuse Aggressive _Hostile —Intimidating
SPECIAL PROBLEMS/ISSUES +o9-11c Check ALL that Apply ANTISOCIAL 196-203
Learning Disability CNS Disorder Language Issues Disrespect Disregards Rules Uses/Cons Others
Loss/Grief _Wetting/Soiling Cultural/Belief Issues —
—Disobedient Dishonest
Eating Disorder Fire Set/Destroy Property — —
LEGAL 204-210
PROBLEM SEVERITY
Legal Problems Probations/Parole Offenses:Property
_
RATE the CURRENT P-SEV(PROBLEM SEVERITYI —Charges Pending —Offenses:Substances —Offenses:Persons
for each area in the boxes provided,using the following scale: VIOLENCE I DANGER TO OTHERS 211-217
None Slight Moderate Severe Extreme
1 - 2 - 3 - 4 - 5 - 6 - 7 - B - 9 Violent Homicidal Ideation
—Assaultive Homicidal Threat/Attempt
CURRENT P-SEV Check ALL Problems that Apply —Phys/Sexual Abuser _Danger to Others (GR3713!3}
EMOTIONAL WITHDRAWAL 117-in FAMILY ISSUES 216.225
Underactive Passive Doesn't Verbalize Feelings
Distant Subdued Blunted Affect No Family/No Contact —Family Legal —Domestic Violence
— m
Out of Home Placement Parenting —Unstable Hoe/Fam
—
DEPRESSION 124-130 Separation/Custody
Depressed Lonely _Hopeless FAMILY PROBLEMS WITH 226-231
_ _
Worthless Sad Dejected Partner Relative
— — Parent —
ANXIETY 171-119 —_Sibling _Child
Anxious Nervous Panic INTERPERSONAL PROBLEMS 232-236
Tense Flashbacks Phobic
Fearful Nightmares/Terrors —w/Friend —Establishing Relationships
— Social Skills _Maintaining Relationships
HYPER AFFECT 140-146 —
Overactive Pressured Speech Elevated Mood ROLE PERFORMANCE(Work/School) 237-243
_
Mood Swings Accelerated Speech Mania
— — — Absenteeism Performance Behavior
ATTENTION PROBLEMS 147-153 —Suspension/Probation —Termination —Limited Employability
Agitated Distractible Attention Span SUBSTANCE ABUSE 244-2.9
Restless Impulsive Concentration
— Problem w Alcohol Dependent/Addicted In Recovery
SUICIDE I DANGER TO SELF 154-160 _Problem w Drugs —Imederes with Responsibilities
Suicide Ideation Self-Injury/Mutilation MEDICALIPHYSICAL 250-256
Suicide Plan Reckless Self-Endangerment Acute Illness _Medical Care Needed Physical Handicap
—Suicide Attempt —Danger to Self iTJ.138 2T-7l7} .. Chronic Illness InjuryByAbuse/Assault —Permanent Disability
THOUGHT PROCESSES 161-169 SECURITY/MANAGEMENT ISSUES 257-265
Bizarre Suspicious Repeated Thought
_ _ _ Seclusion/Time Out Walkaway/Escape Behavior Managemt
Delusions Paranoid Obsessive —
_
— Close Supervision Security Suicide Watch
Hallucinations —Medication Compliance —
— Inadequate Adult Supervision
COGNITIVE PROBLEMS 169-175
Confused Loose Associations Lacks Self Awareness OVERALL DEGREE OF PROBLEM SEVERITY 266
—Disoriented —Disorganized —Impai
sor red Judgement Check ONE Response
_
SELF-CARE I BASIC NEEDS 176-163 None Slight Moderate Severe Extreme
Hygiene DoesnWanage Money Doesn't Provide Food 1 2 3 4 5 6 7 8 9
_
Self Care Problems Doesn't Use Resources Doesn't Provide Housing
—Gravely Disabled 0-,:p ta1': — UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL PROBLEM SEVERITY 267
RESISTIVENESS 184-190 Check ONE Response
Much Much
Resistive Evasive Wary
_ Better Better No Change Worse Worse
-Uncooperative Guarded _Denies Problems
1 2 3 4 5 6 7 8 9
what,_ Rillinn Vellnw—Chart Form#260 R 5/97
COLORADO CLIENT ASSESSMENT RECORD 31
Client I.D. Name Admit Date
STRENGTHS/RESOURCES LEVEL-OF-FUNCTIONING (LOF)
Check ALL CURRENT STRENGTHS/RESOURCES Individual has: Check ONE Response for Each LOF Area
ECONOMIC RESOURCES 268-274 SOCIETAL I ROLE FUNCTIONING 304
Medicaid/Medicare _Employment Transportation Very High Moder High Average Mode Low Very Low
_Other Medical hawHousing Function Function Function Function Function
Other Public Assist Financial
_
1 2 3 4 5 6 7 8 9
EDUCATION/SKILL RESOURCES 278-2» INTERPERSONAL FUNCTIONING 303
Language Skills Interpersonal Skills Intelligence
_ _
_Education
Job Skills — Very High Moder High Average Moder Low Very Low
— Function Function Function Function Function
PERSON RESOURCES 2130-281
Parent(s) _ _
Partner Professional Caregiver 1 2 3 4 5 6 7 8 9
Sibting(s) Child(ren) _Other Supportive Relationship DAILY LIVING/PERSONAL CARE FUNCTIONING Sae
_Relative(s) _Friend(s) Very High Moder High Average Moder Low Very Low
PERSONAL STRENGTHS 218-301Function Function Function Function Function
_U ne keabless Emotional Stability Adaptability 1 2 3 4 5 6 7 8 9
Appearance _ _
Health Thought_
PHYSICAL FUNCTIONING 307
Confidence Hopefulness Resourcefulness
_ _ Very High Moder High Average Moder Low Very Low
_Judgement Responsibility Toleranncee
_Empathy __Insight Function Function Function Function Function
1 2 3 4 5 6 7 8 9
COGNITIVE/INTELLECTUAL FUNCTIONING 309
Very High Moder High Average Moder Low Very Low
Function Function Function Function Function
1 2 3 4 5 6 7 8 9
CURRENT OVERALL STRENGTHS/RESOURCES 302 OVERALL LEVEL OF FUNCTIONING Check ONE Response 309
Check ONE Response Very High Moder High Average
gg Mader Low Very Low
Very High High Moderate Some Very Low Function Function Function Function Function
1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL STRENGTHS/RESOURCES 303 CHANGE IN LEVEL OF FUNCTIONING Check ONE Response 3W
Check ONE Response Much Much
Much Much Better Better No Change Worse Worse
Better Better No Change Worse Worse
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
I I I I I I I I I STAFF ID 311-319 STAFF SIGNATURE
I1DISCIPLINE' 1=none 2=mh worker 3=nursing 4=social work 5=psychology 6=psychiatry 7=other no
[1 DEGREE: 1=none 2=ascariate 3=bachelors 4=masters 5=PhD/PsyD/EdD 6=MD 7=other 321
COMPLETE THIS BOX ONLY FOR COMPLETE THIS BOX ONLY AT DISCHARGE
UPDATE,ACTIVATE AND INACTIVATE STATUS
DATE FORM COMPLETED
MONTH DAY YEAR 330-337
LAST CONTACT DATE
MONTH DAY YEAR 338345
EFFECTIVE DATE 322-329 [ DISCHARGE DATE
MONTH DAY YEAR MONTH DAY YEAR 346353
I-7 TYPE OF TERMINATION- 334
SPECIAL STUDIES 1'Discharged/Transferred 5 From Inactive
2-TX Completed/No Referral 6-Patient/Client Died
]37 3-TX Completed/Follow-up 7-PatieM/CIieM Terminated
InEvaluation Only
367-3Ts TERMINATION REFERRAL- 355-35S
NOTE: Use 61 'Self' f no Referral
White— Billing Yellow—Chart Form#270 R 5/97
INTEGRATED ASSESSMENTS FOR GOAL DEVELOPMENT
Client Name: Client# DOB:
Admission Date: Clinician:
AGGRESSIVENESS/SELF OR OTHERS (Homicidal/Suicidal/Self-destructive)
ASSESSMENT:
History Clinical Assessment
Intake Assessment Other
Psych. Assessment To Be Assessed
Findings/Assessment Results:
_ STRENGTH: Not A Treatment Issue At This Time
Focus Of Treatment (Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale
FUNCTIONAL
COMMUNICATION/PROCESSING ISSUES
ASSESSMENT:
History Psych. Assessment
Intake Assessment Clinical Assessment
Speech/Language Assessment To Be Assessed
Other
Findings/Assessment Results:
1
STRENGTH: Not A Treatment Issue At This Time
Focus Of Treatment(Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale:
DAILY LIVNG SKILLS:
ASSESSMENT:
History Psych Assessment
Observation Other
Clinical Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH:Not A Treatment Issue At This Time
Focus of Treatment: (Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
EDUCATION
ASSESSMENT:
Academic Testing Other
History _ To Be Assessed
Observation
Findings/Assessment Results:
2
STRENGTH:Not a Treatment Issue At This Time
Focus of Treatment: (Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
PHYSICAL/NEUROLOGICAL
ASSESSMENTS:
History OT/PT Assessment
Clinical Assessment Other
Psych Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH: Not A Treatment Issue At This Time
Focus of Treatment(Refer to Goal Sheet)
Defer Priestly: Clinical Rationale
SOCIAL SKILLS:
ASSESSMENT:
History Other
Clinical Assessment Intake Assessment
Psych Assessment To Be Assessed
Findings/Assessment Results:
3
STRENGTH: Not a Treatment Issue At This Time
Focus of Treatment(Refer to Goal Sheet)
_ Defer Presently: Clinical Rationale
MENTAL STATUS
THOUGHT PERCEPTION OR JUDGEMENT ISSUES
ASSESSMENT:
History Other
Psych Assessment Intake Assessment
Clinical Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH:Not a Treatment Issue At This Time
Focus of Treatment(Refer to Goal Sheet)
Defer Presently: Clinical Rationale
MOOD/AFFECT
ASSESSMENT:
History Other
Psych Assessment Intake Assessment
Clinical Assessment To Be Assessed
4
Findings/Assessment Results:
STRENGTH: Not a Treatment Issue
Focus of Treatment(Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
SEXUAL REACTIVE OR PERPITRATION ISSUES:
ASSESSMENT:
History/Physical M.D. Assessment
Medical Illness _ Other
Psych Assessment To Be Assessed
Intake Assessment
Findings/Assessment Results:
STRENGTH:Not a Treatment Issue:
Focus of Treatment(Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
5
TRAUMA RELATED ISSUES: (Abuse/neglect/attachment issues)
ASSESSMENT:
History Clinical Assessment
Intake Assessment Other
Psych. Assessment
Finding/Assessment Results:
STRENGTH: Not A Treatment Issue At This Time
Focus Of Treatment(Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale
OTHER CHALLENGING BEHAVIORS:
ASSESSMENTS:
History Clinical Assessment
Intake Assessment Other
Legal Involvement To Be Assessed
Psych Assessment
Findings/Assessment Results:
6
STRENGTHS:Not a Treatment Issue
Focus of Treatment(Refer to Goal Sheet)
Defer Presently : Clinical Rationale
HEALTH ISSUES:
ASSESSMENTS:
History Clinical Assessment
Intake Assessment Other
Psyche Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH:Not a Treatment Issue
Focus of treatment(Refer to Goal sheet)
Defer Presently Clinical Rationale:
SUBSTANCE ABUSE ISSUES:
ASSESSMENT:
History Clinical Assessment
Intake Assessment Other
Psych. Assessment To Be Assessed
Findings/Assessment Results:
7
Strength: Not a Treatment Issue At This Time
Focus of Treatment(Refer To Goal Sheet)
Defer Presently: Provide Clinical Rationale
FAMILY/GUARDIAN TREATMENT ISSUES:
ASSESSMENTS:
History Pscyh Assessment
Intake Assessment Other
Clinical Assessment To Be Assessed
Findings/Assessment Results:
STRENGTH: Not a Treatment Issue At This Time
Focus of Treatment:(Refer to Goal Sheet)
Defer Presently: Clinical Rationale:
CASEMANAGEMENT RESPONSIBILITIES:
Describe out-side sources involved in Client's treatment and on-going responsibilities of Littler Staff in
regards to these resources. Include understanding of responsibility of out-side source discharge planning as
well.
8
SUMMARY OF STRENGTHS FOR THIS CLIENT TO BE USED IN
TREATMENT:
JUSTIFICATION FOR TREATMENT:
Decomposition of Psychiatric Illness
Medication Management/Stabilization
Continued Treatment Failures at other Placements or Less Restrictive Levels of Care
Crisis Stabilization Escalation of Behavior Problems Safety Issues
Other: (please State) -
JUSTIFICATION FOR LEVEL OF CARE:
9
DISCHARGE CRITERIA:
Absence of suicidal/self destructive behavior
Management/Self Management of Aggressive Behavior
Medication Stabilization
Stabilization of Psychiatric Illness
Management/Self Management of Feelings Causing Affective or Behavioral Issues
Determination of an appropriate Discharge Placement
Other(please specify)
Other(please specify)
DISCHARGE PLAN/FOLLOW-UP NEEDS:
_ Return to Parent/Guardian Intensive Family Treatment
FosterCare Placement _ Medication Management
Group Home Medical Treatment
Return to Public School _ OT/PT Services
Long Term Treatment Placement Perpetration Treatment(Group or
Individual)
Special Education Program Individual Therapy
Mentor/Community Referral(specify)
Other(specify)
Other(specify)
10
Supplemental Narrative to RFP:
Exhibit B
Recommendation(s)
RFP: 01006-Day Treatment
North Range Behavioral Health
,. , ;3 Rif12: CO
t2 1 ,!
North Range
Behavioral Health Ed Jordan
President
Judy Richter,RN.,Ph.D
Vice-President
Michele Vetting
Secretary
May 18, 2001 Sally Warde
Treasurer
Alvina Der era
Past President
Frank Aaron, Social Services Administrator
Weld County Department of Social Services
PO Box A
Greeley, Co. 80632
Dear Frank:
Thank you and Judy for the letter of May 1, in which Judy reported the results of
the RFP Bid process for PY 2001-02. We see no difficulty with the additional
recommendations. We will incorporate the recommendations by providing
additional communication to Department staff, and by assuring that the treatment
plans for day treatment clients will focus on the primary goals of evaluating youth
for out-of-home placement and returning the youth to their home and to public
school when appropriate.
Please contact me if there is a need for any further information.
Sincerely,
pel
Dale F. Peterson, LCSW, MHA
Executive Director
1306 11th Avenue/Greeley,CO 80631/(970)353-3686/Fax(970)453.3906
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DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY,CO 80632
VI WEBSITE:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(910)352-6933
COLORADO
w DO May 11, 2001
Mr. Dale Peterson,Director
North Range Behavioral Health,Inc.
1306 11 Avenue
Greeley, CO 80361
Dear Mr. Peterson: •
Re: RFP 01006, The Littler Center,Day Treatment
Dear Mr. Peterson:
The purpose of this letter is to outline the results of the RFP Bid process for PY 2001-
2002 and to request written information or confirmation from you by Wednesday, May
23, 2001.
A. Results of the RFP Bid Process for PY 2001-2002
Through the 2001-2002 Core Services bid evaluation process,the Families, Youth
and Children(FYC) Commission approved the RFP(s) listed above for inclusion
on our vendor list. The FYC Commission attached the following
recommendations and/or conditions regarding your RFP bid(s).
RFP 01006,Day Treatment:
Recommendations:
1. North Range Behavioral Health will make more of an effort to maintain
communication with Department staff.
2. North Range Behavioral Health will focus on the primary goals of
evaluating youth for out-of-home placement and returning the youth to
their home and to public school when appropriate.
B. Required Response by RFP Bidden Concerning FYC Commission
Recommendations.
The Weld County Department of Social Services is requesting your written
response to the FYC Commission's recommendation. Please respond in writing
to Frank Aaron, Social Services Administrator,P.O. Box A, Greeley, CO, 80632,
by Wednesday,May 23,2001, close of business.
You are requested to review the FYC Commission recommendations and to:
a. accept the recommendation(s) as written by the FYC Commission;
or
b. request alternatives to the FYC Commission's recommendation(s);
or
c. not accept the recommendation(s)of the FYC Commission.
Please provide in writing how you will incorporate the recommendation(s)into
your bid. If you do not accept the recommendation,please provide written
reasons why. If you do not accept the recommendation,please provide reasons
why. All approved recommendations under the NOFAA will be monitored and
evaluated by the FYC Commission.
If you wish to arrange a meeting to discuss the above conditions and/or
recommendations, please do so through Elaine Furister, 352.1551, extension 6295, and
one will be arranged prior to Wednesday,May 23, 2001.
Sincerely,
J y e ,Director
ldbunty epartment of Social Services
cc: Dick Palmisano, Chair, FYC Commission
Frank Aaron, Social Services Administrator
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