HomeMy WebLinkAbout20011397.tiff RESOLUTION
RE: APPROVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARD FOR FOSTER
PARENT CONSULTATION 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 a Notification of Financial Assistance
Award for Foster Parent Consultation 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, 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 Foster Parent Consultation 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 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
ATTEST: /�1 � /all Las ,iii _fay
M. J Geile, C it
Weld County Clerk to t � , �
t� Glenn Vaa , ro- em
BY: Gi
Deputy Clerk to the B.'
Willia erke
APPR AS T�FORM:
A (4y
D vi Long
LL
ty ey ' id
Robert D. as en
2001-1397
`/fie 5 SS0028
1411614:M4 DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY,CO 80632
' WEBSITE:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
O Child Support(970)352-6933
COLORADO
MEMORANDUM
TO: M. J. Geile, Chair Date: May 23, 2001
Board of County Commissioners
FR: Judy Griego, Director C
Weld County Departme of S cial rvi es
RE: PY 2001-2002 Notification of Financial Assistance Awards (NOFAA) under Core
Services Funds-Ackerman& Associates, P.C.
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 proposals under a
Request for Proposal process and are recommending approval of these bids.
Ackerman and Associates, P.C.
A. Option B, Home Based Intensive: A maximum of 84 families for an average of
three hours per week of in-home services for a 20-week period. The average
length of stay will be 60 hours. Rate is$99.50/hour per unit of service.
B. Intensive Family Therapy:
1. Mediated Family Conflict Resolution and Short-term Intensive Family
Therapy-Goal Achievement Program(GAP): A maximum of 14 families
per month. Average capacity is five families per month (60 per year).
Maximum stay is 20 hours over a five-month period. The program has a
capacity of providing Bicultural-bilingual services to 15 families per year.
Rate is$99.50/hour.
Page 1 of 2
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MEMORANDUM TO M. J. GEILE,CHAIR
WELD COUNTY BOARD OF COMMISSIONERS
RE: CORE SERVICE NOFAA PY 2001-2002
2. Family Group Decision Making: A maximum of four families per month
(48 per year) involving the nuclear family,professionals involved in the
case, and individual members of the extended family. Rate is$2,000 per
family group conference.
C. Sex Abuse Treatment: Projected maximum total per year is estimated at 36
families, the average monthly capacity is three families, the maximum stay is 46
sessions over a 12-month period. Group treatment is provided at an equivalent of
five individual hour-long sessions. Rate is$99.50/hour.
D. Foster Parent Consultation: Group training for a maximum of 12 participants with
an average of four participants per group. Average stay is 12.5 hours. Telephone
consultations for crisis management are available for a maximum of one-half
hour per call. This program anticipates serving 60 family units. Rate is $90 an
hour. Group rate per client is$45/hour.
If you have any questions, please telephone me at extension 6510.
of
Page 2 of 2
vvemu Lounty Department of aoctat services
Notification of Financial Assistance Award
for Families,Youth and Children Commission (Core)Funds
Type of Action Contract Award No
X Initial Award FY01-CPS-2
Revision (RFP-FYC-016-00)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2001 and Ackerman and Associates,P.C.
Ending 05/31/2002 Foster Parent Consultation
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).
This program provides foster parent consultative The RFP specifies the scope of services and conditions
services in the areas of(1)consultation and foster of award. Except where it is in conflict with this
parent support, (2) mandated corrective action NOFAA in which case the NOFAA governs, the RFP
consultation, and (3) mandated critical care upon which this award is based is an integral part of the
consultation. The programs will be provided action.
through individual services in the home of the
foster parent or in the office. Group training will Special conditions
be provided for a maximum of 12 participants
with an average of four participants per group. 1) Reimbursement for the Unit of Services will be based
Average stay is 12.5 hours. Telephone on an hourly rate per child or per family.
consultations for crisis management will be 2) The hourly rate will be paid for only direct face to face
available for a maximum of one-half hour per call. contact with the foster parent and/or family, and as
This program anticipates serving 60 family units. specified in the unit of cost computation.
3) Unit of service costs cannot exceed the hourly and
Co t Per nit of ervice yearly cost per child and/or family.
4) Payment will only be remitted on foster parents, and
Hourly Rate Per $90.OQ referrals made by the Weld County Department of
Group Rate $45.00 Social Services Certified Foster Parents.
Unit of Service Based on Approved Plan 5) Requests for payment must be an original and submitted
Enclosures: to the Weld County Department of Social Services by
X Signed RFP:Exhibit A the end of the 25th calendar day following the end of the
Supplemental Narrative to RFP: Exhibit B month of service. The provider must submit requests
Recommendation(s) for payment on forms approved by the Weld County
Conditions of Approval Department of Social Services.
Approv /.' Program Official:
B le, B
M. J. G Chair Judy GritDire or IP
Board of Weld County Commissioners Weld ounty Department of Social Services
Date: 05 -, -avv/ Date: 5f 01.3101
2oo/- /3Q7
Signed RFP: Exhibit A
Ackerman & Associates
RFP: 01-060-Foster Parent Consultation
r
INVITATION TO BID
016-00 I-Os-re r Parent Ce,tci ,/re.170A
DATE:February 28, 2001 BID NO: 016-00
RETURN BID TO: Pat Persichino,Director of General Services
915 10th Street,P.O. Box 758, Greeley, CO 80632
SUMMARY
Request for Proposal (016-00) for: Family Preservation Program—Foster Parent
Consultation
Fami y Issue's Cash Fund or Family Preservation
Program Funds
Deadline: March 23, 2001, Tuesday, 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 Foster Parent Consultation Program must
provide services that focus on providing psychological consultations and parenting support to foster parents
which are designed to improve foster parent 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 March 19,20(11 �oQ ��C� .,,�,,..\�c t).
(After receipt of order) M T BE SIGNED IN INK
Joyce Shohet Ackerman, Ed.D.
TYPED OR PRINTED SIGNATURE \ �n
VENDOR Ackerman and Associates P.C. k t
(Name) written Signature By Authorized
Officer or Agent of Vender
ADDRESS 1750 25th Avenue Court TITLE President, Licensed Psychologist
Greeley, Co. 80634 DATE March 19, 2')01
PHONE# 970 353 3373
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 30
I' .
016-00 Attached A
FOSTER PARENT CONSULTATION PROGRAM BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING
FAMILY PRESERVATION PROGRAM
2001-2002 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 2001-2002
BID#016-00
NAME OF AGENCY: Ackerman and Associa-keg P C
ADDRESS: 1750 25th AWenue, Greeley, CO 80634
PHONE: ( 470)353-3373
CONTACT PERSON: Joyce Shohet, A kenuan Ed.D. TITLE: pv'esident, Licensed Psychol -
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Foster Parent Consultation (7/Jr
Program Category mustprovide services that focus on teaching life skills designed to facilitate implementation of
the case plan •by improving household management competencyparental comp to encX familyon conflict
management and effectively accessing community resources.
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:
AMOUNT QUESTED:
Joyce Shohet Ackerman Ed.D. March 19, 2001
Name and Signature of Person Preparing Document Date
Joyce Shohet Ackerman, Ed.D.
�\ aa..� ,sA, N►,Sn.... ,..,„�\...ct), March 19, 2001
Name an t atute 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 2000-2001 to Program Fund year 2001-2002.
Indicate No Change from FY 2000-2001 to 2001-2002
Project Description
X Target/Eligibility Populations k
t Types of services Provided ,c
?t Measurable Outcomes $
K Service Objectives x
_t Workload Standards x
Staff Qualifications X
X Unit of Service Rate Computation I.
___x_ Program Capacity per Month K
Certificate of Insurance
fLp m,tar cL.7cc.
Page 24 of 30 / //
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•
•
016-00
Attached A
Date of Meeting(s)with Social Services Division Supervisor:
Comments by SSD Supervisor:
4 ,0i,,,Ls=srs
fasY
ame and Signa e of SSD ' pervisor Date 3437/
Page 25 of 30
016-00 Attached A
Program Category Foster Parent Consultation
Project Title
Vendor Ackerman and Associates Foster Parent Consultation Program
Ackerman and Associates P.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. The monthly maximum program capacity.
G. The monthly average capacity.
H. Average stay in the program (weeks).
I. Average hours per week in the program.
III. TYPE OF SERVICES TO BE PROVIDED
Provide a two-page description of the types of services to be provided. Please address if your project
will provide the service minimums as follows:
A. Consultation and Foster Parent Support around placement issues, behavioral management,
foster home issues involving biological children in the home, transition and loss issues,work
with foster parents and caseworkers around interpretation and implementation of treatment
plans, discipline in the home, group training for foster parents-access to training materials,
work with foster adopt parents on legal risk and commitment issues, visitation issues, and
solution oriented planning.
B. Mandated training for foster parents under corrective action plans and follow-up services as
needed.
C. Mandated consultation services for identified critical care foster parents.
D. Assure the foster parent consultation will not be provided by a professional staff member who
is providing therapeutic services to foster children in the same home.
E. Assure that all assessments, clinical recommendations, and other opinions derived by the
contractor in the performance of this contract will be shared directly with the assigned
caseworker of the children involved. If there is disagreement over the implementation of the
treatment plan with the caseworker, a meeting shall be held with the contractor, assigned
caseworker, foster parents, and the caseworker's supervisor. The objective will be to
determine a unified departmental response for the court. The contractor will not use the legal
system to oppose the department's recommendations.
Page 26 of 30
016-00 Attached A
F. Agrees to comply with 19-1-120 C.R.S.,which requires that reports of child abuse and any
identifying information in those reports are strictly confidential.
Provide your quantitative measures as they directly relate to each service. At a minimum, include a
number to be served in each service component. Describe your internal process to assure that FYC
resources will not supplant existing and available services in the community; e.g. mental health
capitation services, ADAD and professional services otherwise funded.
IV. MEASURABLE OUTCOMES
Provide a two-page description of your expected measurable outcomes of the project. Address the
following measurable outcomes:
A. Improvement of household management competency as measured by pre and post assessment
instruments.
B. Improvement of parental competency as measured by pre and post assessment instruments.
C. Foster parents can independently work with other sources in the community and within the
local, state, and federal governments.
D. Foster parents have demonstrated higher skill and competency levels in fulfilling their
designated function for children in out-of-home placement.
E. Foster parents have positively met the needs of their biological children in adjusting to and
coping with the presence of foster children in the home.
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 Household Management Competency- capacity of parents to provide safe
household environment for their children through competent household cleaning and
maintenance,budgeting and purchasing.
B. Improve Parental Competency- capacity of parents to maintain sound relationships with their
children and foster 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 ahead the local, state, and federal governments.
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.
Page 27 of 30
016-00 Attached A
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, 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.
Page 28 of 30
016-00 Attached A
III. 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 I �S Hours [A]
Total Clients to be Served ` Clients [B]
Total Hours of Direct Service for Year 7 rO Hours [C]
(Line [A] Multiplied by Line [B] '' �,/
Cost per Hour of Direct Services $ 5"/ Per Hour [D]
Total Direct Service Costs $ WO SOO [E]
(Line [C] Multiplied by Line [D] )
Administration Costs Allocable to Program $ / 3 S-0 [F]
Overhead Costs Allocable to Program $ i3 coo [G]
Total Cost, Direct and Allocated, of Program$ 6 7, YO 0 [H]
Line [E] Plus Line [F] Plus Line [G1 )
Anticipated Profits Contributed by this Program $ 0 [I]
Total Costs and Profits to be Covered O O
by this Program(Line [H] Plus Line [I] ) $ V [J]
Total Hours of Direct Service for Year 75-01 [K]
(Must Equal Line [C] )
Rate per Hour of Direct, Face-to-Face Service CAS", oo/(1 -
to be Charged to Weld County Department of p
Social Services $ l U' �� [L] Iww ror
Saitletax
Day Treatment Programs Only: . Che
Direct Service House Per Client Per Month [M]
Monthly Direct Service Rate $ [N]
Page 29 of 30
Project Description 2001-2002
ACKERMAN AND ASSOCIATES' FOSTER PARENT SERVICES
I. Overview:Ackerman and Associates, P.C. has provided Foster Parent
Consultation Services to Weld County over the past four years. We propose to
continue to provide foster parent consultative services in the following areas:
1. Voluntary Consultation and Foster Parent Support concerning:
a. placement issues,
b behavioral management,
c. foster home issues involving the biological children in the home,
d transition and loss issues,
e. assistance in the interpretation and implementation of treatment
plans in coordination with foster parents and caseworkers in accord
with the requirements of the contract,
f. discipline in the home, and including a 24 hour telephone
access line for foster parent questions - the Cool Line,
g. training for foster parents and access to training materials,
including group and individual training for continuing education
credits. Also, in selected cases, "Internet Searches"to help identify
resources, such as support groups for foster parents with
children with specific conditions, provision of in home seminars to
deliver workshop services in a effective manner to foster homes,
h. work with all foster parents on legal risk and commitment issues,
visitation issues and solution oriented planning.
i. facilitation of the networking of foster parents particularly in terms of
identified subgroups such as group home issues, issues in common
to kinship homes, issues for on kinship homes etc.
We will provide such services to those foster parents who voluntarily
participate in such services for the benefit of themselves, their children
and foster children.
2. Mandated Corrective Action Consultation in the above areas to those
foster parents who are under corrective action orders and to provide
them follow up services as needed. The services listed in No. 1 above
will be provided.
3. Mandated Critical Care Consultation services for identified critical
care foster parents. The services listed in No. 1 above will be provided.
We will provide these programs through individual services in the home of the foster
1
parent or in our offices. Group training will be provided for a maximum of twelve
participants with an average of four participants per group. Telephone consultations
for crisis management will be available for a maximum of one half hour per call.
Yearly maximums per foster parent are set in the proposal to prevent excessive
demand for services by any individual foster parent. Renewals for any family beyond
this amount will need to be approved by the clinical director of this program
Target/Eligibility Populations
A Total number of clients to be served in this twelve month program has been
calculated as follows. There are approximately seventy five foster family homes under
WCDSS sponsorship. Our past work has reached about 40-50% of these homes with
one or more contacts per year. The majority of these contacts have been in training for
continuing education credit. That number includes at least 30 individuals who are
foster parents. We have the capacity to serve more than this number if demand for the
services is there especially in seminars and training. We projected our maximum
capacity for last year as seventy five families and expected 60 families to be served.
B. Distribution of clients. On a program by program basis we expect to serve, 30-50
families for continuing education credits in groups in the office or seminars in their
homes, about five families for corrective action, about 10 - 15 families for critical
foster care, and about 25 families for individual consultation in their homes. Many
families will access more than one service. We will set an upper limit on services
received by any one family in volunteer contact to 30 hours over the year unless
approved in writing by the clinical director of this program.
C. Families Served. We anticipate serving 60 family units with at least one contact and
approximately 40 families with more than one contact, based on our use patterns and
the level of trust built with foster families over the past four years.
D. Sub total who will receive bicultural/bilingual services. We anticipate we can
serve 100% of families who need these services in a bilingual manner. All of the staff
have extensive cross cultural experience.
We have an Hispanic member of the staff, Emily Jaramillo, M.A., L.P.C. is fluent in
Spanish. She has been assisting in foster parent consultation for the several years.
Joyce Ackerman, Ed.D. has spent several years working in American Indian
reservation populations and with Hispanic mental health in Greeley. She has
practiced in Greeley since 1981. Larry Kerrigan, Ph.D. has more than twenty five years
experience as a therapist in Greeley working with the Hispanic population through the
Weld Mental Health Center. Susan Bromley, M.S.W., Psy.D. is both a trained social
worker and a practicing psychologist with extensive experience training students in
cross cultural sensitivity. Sherri Malloy, Ph.D., who has bicultural experience at the
2
Boulder Mental Health Center also has been doing foster parent support work for the
past year. Nicole Wamygora, M.A., L.P.C., who also has worked with our foster parent
program over the past year and Cassie Yackley M.S. L.P.C. and Karen Bender, M.A.,
L.P.C., each have clinical experience with bicultural families and have worked in our
foster parent program in the last year.
E. We understand there are 11 foster families in South County at the present time.
Home based consultation in South County will be the normal mode of service delivery
and has been available at the level needed for this contract to cover 100% of these
homes. If for some reason home based consultation is not appropriate and service
delivery at our offices in Greeley is not practical, we can provide services in South
County if Social Services can provide a site to do such work.
F. Accessibility. On weekdays, all providers of Ackerman and Associates are
accessible through our office secretary and through cell phones and pagers. After
hours we maintain a 24 hour answering service and pager system. On weekends,
this 24 hour access reaches the provider on call who is always a licensed Mental
Health provider.
G. Maximum per month. The program maximum is estimated below by program
area
Group training or workshops 150 hours per month billed as
75 hours a month at bid rate.
Individual Consultation in homes 40 hours a month
Mandated Training for Corrective Action 40 hours a month
Mandated Training Critical Care 40 hours a month.
Cool line maximum per contact is one-half hour of billing. No individual can produce
more than 10 cool line contacts (5 hours) per year. For individual foster parents in
remote areas of the county (more than a fifty mile trip each way to Greeley) cool line
services may be expanded above this limit by the program supervisor. No more than
75 hours total per year can be billed to the services provided over the Cool Line. This
represents eight calls per family per year as a projected maximum for cool line
expenditures. The projected monthly maximum for the cool line is 15 hours and we
expect to operate at about six hours per month.
Monthly patterns are difficult to estimate. The yearly maximum for the contract is set at
750 hours at $90 per hour. In fact, many services in group are billed at the group rate
of $45 per credit hour so three hundred billable hours for group actually represent 600
hours of training. The contract billable maximum for any combination of services is
$67,500 per contract year.
H. The monthly average capacity is 65 hours per month.
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I. The average stay in the program is expected to be between 10 and 15 hours
(average 12.5 hours) over the year period for 60 families. The maximum stay is 30
hours over a one year period except in the mandated corrective and critical care
programs which are not limited. Group treatment would be used at a rate of one half
of the proposed rate of this bid so each hour of group treatment would be equivalent
to one half hour of individual treatment.
Types of Services Provided
1. Consultation and Foster Parent Support on a voluntary basis concerning:
a. placement issues,
b behavioral management,
c. foster home issues involving the biological children in the home,
d transition and loss issues,
e. assistance in the interpretation and implementation of treatment
plans in coordination with foster parents and caseworkers in accord
with the requirements of the contract.
f. discipline in the home, and including a 24 hour telephone
access line for foster parent questions - the Cool Line
g. training for foster parents and access to training materials,
including group and individual training for continuing education
credits,
h. work with foster parents on legal risk and commitment issues,
visitation issues and solution oriented planning. Emphasis in this
area includes: How to structure your home to avoid triggering an
investigation by preventing accidents, What to look for in a baby sitter,
Being a foster parent in a regulatory world and similar topics.
2. Mandated Corrective Consultation in the above areas to those foster
parents who are under corrective action orders. We will provide them follow
up services as needed.
3. Mandated Critical Care Consultation services for identified critical care
foster parents.
A partial list of the types of workshops and seminars we have provided over the last
three years follows:
Separation and Loss, Understanding Prescription Medications, Discipline,
Assertiveness with Systems, Drug Abuse, Eating Disorders, Child Development,
Sexual Abuse and Sexual Behavior- What's Normal With Young Children, Sexual
Abuse and Sexual Behavior- What's Normal With Teens, Recovery From Prenatal
Trauma - What To Expect, Anger Management, Stress Reduction, Parenting Round
4
Tables, Parenting with Love and Logic.
We have provided all proposed services, Corrective Consultation Services, and critical
care services for two years.
We have been providing these services on a voluntary basis for foster parents over the
past four years for Weld County Department of Social Services. Our longest running
program experience has been in continuing education and individual consultation.
For the mandated programs we have developed response standards to 1) insure that
we deliver services promptly and 2) report to social services if there is any difficulty in
compliance with the corrective actions required. The mandated consultation
programs are analogous to home based delivery of services in respect to keeping in
close contact with the caseworker or in this case the foster parent supervisor.
In our opinion, reporting in relation to the voluntary use of Foster Parent Consultation
Services is a different case. Up to this point, we have used an Employee Assistance
Model in the delivery of consultation services to those who voluntarily seek them. Such
a model requires the foster parent to be assured that they have confidentiality in
discussing their issues with the consultant and that the consultant does not function
as a conduit for all issues discussed with the caseworker. Such confidentiality is
useful and necessary in some circumstances such as the cool line. Many foster
parents perceive that seeking instruction may be seen by Social Services as a sign of
personal deficiency on the part of the foster parent. Seeking of appropriate
consultation should be actively encouraged. The maintenance of a non-adversarial
and non-punitive atmosphere is especially important for consultation. We propose to
continue to use such a framework for work with foster parents except under strictly
defined circumstances. These circumstances constitute a clarification of the
language to section Ill E of the RFP for this bid as originally stated in the bid process
of 2001-2001.
These strictly defined circumstances relate to those foster parents only as
consultation relates to item le above - differences in the implementation of the
treatment plan as perceived by the consultant between social services and the foster
parent. The following language reflects agreements we have had in place with Social
Services for the last year (and have not needed to make use of). We propose to
continue to operate under this successful mechanism.
Where perceived differences clearly appear to relate to child safety, the consultant will
be bound by law to report to Social Services. Where the differences in interpretation of
the care plan clearly do not involve child safety, the consultant will seek to have the
foster parent and the caseworker discuss these directly.
In instances where the desires of the foster parent and those of social services clearly
differ in relation to some aspect of the foster placement treatment plan and where
5
there is no apparent issue of child safety involved, the mechanism outlined in section
IIIE would seem to apply.
However, the consultants will not serve as advocates for the parents or for social
services in such cases of dispute. Our role with the foster parent is to provide training,
not to conduct assessments to discover the failures of the foster parent or to seek to
alter the treatment plan for the foster child. Neither will the consultants serve as a
conduit primarily for collecting information for the caseworker on the foster parent in a
dispute. As trust is essential to this process, we have worked in and intend to
continue to work in an environment of trust with all parties.
Hopefully, any dispute can be discussed to find common ground in a meeting with the
foster parents, the caseworker, the foster parent supervisor, the case workers
supervisor and the consultant should such instances arise. As contractors, we will not
initiate action with the courts on a consultation case. If under subpoena for any reason
such that we are required to appear before a court, we will inform the court of this
contractual restriction. We will also be obligated to obey the requirements of the court
should such a situation arise.
We also assure WCDSS as we have in the past that no individual working with
Ackerman and Associates and providing therapy to a foster child in a foster home will
concurrently provide consultation in that home, thus avoiding any appearance of
conflict of interest..
We will provide quantitative measures for group courses similar to the format used in
Continuing Medical Education for medical providers. We will provide a workshop
evaluation form for each workshop. We will establish a work plan for individual
consultation and show completion of that work plan through documented chart notes.
Foster parents will be referred to other resources in the community for provision of
services if they need such resources. We will develop a checklist for services that may
be of use to foster parents outside of WCDSS funds and include this completed
worksheet in each file. A copy will be given to the foster parent and so documented in
the chart. A disclosure stating foster parent agreement to participate in these
programs will be signed by every foster parent prior to treatment (with the exception of
the cool line).
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. How did the foster family come into the foster parent support program?
(voluntary or mandatory)?
6
aooi-i397
2. Did the family attend the workshops they signed up for?
3. Did the foster parent complete the evaluation forms?
4. Did the foster parent need the Cool Line?, individual consultation?,
5 How many hours of total contact did the foster parent have and how many
credits were earned?
Summative outcomes
A Was there improvement in household management competency as measured
by pm and post assessment?
We will use a pre and post clinical assessment based on a therapist rating of
improvement for this area.
B. Was there improvement in parenting competency as measured by pm and post
assessment?
For the workshop setting, a measurement will measure the value the information
obtained through the workshop and for the foster parent. For individual consultation,
an individual consultation plan will be developed in the first hour and completed and
reviewed in the final hour of consultation to ascertain if the consultation goals were
met.
C. Were Foster parents enabled to better work with other sources in the
community and the local state and federal government?
Knowledge of resources can be determined from a listing of resources by the
participants at the outset and the conclusion of the consultation.
D. Did foster parents demonstrate higher skills and competency levels in fulfilling_
their roles for children in out of home placements?
Individualized treatment will be based on change from the initial to the final session
as documented in a summary of the consultant's notes. The foster parents rating of
how information in workshops helped with their foster child will be collected. The
format is included in this proposal.
E. Did foster parents meet the needs of their biological children in adjusting to and
coping with foster children in their home?
A self report question will ask the foster parent if the information presented was
helpful for their biological children. That form is included in this proposal
7
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Service objectives
We have the following service objectives:
A Improvement of Household Management Competency By using a checklist for
individual consultation, we will ascertain if the parents are requesting assistance in
relation to issues related to maintaining a safe household environment. The check list
will include the foster parents assessment if assistance is needed in the following
areas - household cleaning, household maintenance, budgeting or purchasing. We
expect this to be a minor area of work except in families where corrective action may
be needed.
B. Improvement of parental competency We expect this to be the major area of work
with regard to the foster parent's support program. Particular service goals for each
foster parent family will be documented in their chart. A summary of the foster parents
participation will be made for all months of participation.
C. The ability of the family to access resources By using a checklist for families in
individual consultation concerning resources related to specific areas of need, the
referrals to local and governmental resources will be documented. In addition, for
some families an Internet Search will be run to identify further resources to assist
them with specific questions if these concerns have not already been answered. This
Internet option will likely be of use for families with foster children who have unusual
medical or psychological needs. For those in a workshop, listing of resources by
participants before and after the workshop will reflect increased knowledge of
resources.
The methods used to document the service objectives will be a comparison of the
goals of the individual plan for the family with the progress report completed each
month for all families in individual treatment. For those in group treatment, a pre
workshop/post workshop form will be used. Examples of these types of evaluation
tool are appended to this proposal.
Workload Standards
A. The program has a capacity of 195 hours per month. The total per year will not
exceed 750 hours. We anticipate an average of fifty. At each meeting, one therapist is
present. This represents 750 hours of therapist/client time per year. At our rate of $90
per hour, the cost maximum is $67,500 per year. The monthly average is $5625 if we
assume a use of 12.5 hours of the program by 60 families over the year. We have
structured the bid to include the cool line as the only service that is not face to face.
We have set its maximum use per any individual at five hours total and set its
maximum level at 75 hours for the year (a maximum of 10% of the services) or a total
8
of $6750 maximum that can be billed for Cool Line services. This allow two cool line
calls per year per family as the average.
B . There are eight providers — four licensed psychologists, three professional
counselors and a bilingual master's level therapist (soon to also be a LPC) who will
provide these services. All have specific training in helping to assist individuals in
behavioral changes. All have experience in psychoeducational instruction.
C. The maximum caseload The monthly total average will be 62.5 hours.
D. The modality of treatment is consultation for individual or group settings.
E. Hours/month The total number of therapist hours is a maximum of 150 per month
and a maximum of 750 per year. WE expect to operate at about sixty hours per month.
F. Staff There are eight individual providers supported by two administrative
professionals in the practice.
G. Supervisor This contract would be supervised by Joyce Shohet Ackerman, Ed.D.,
who would monitor the project for compliance. Providers are individually licensed and
do not require clinical supervision except for one therapist who is being supervised by
a licensed psychologist in the practice. The maximum caseload per supervisor is 60
families per year. Caseload monitoring would be through tracking of time per foster
parent.
H Insurance All providers carry one million/three million professional liability.
Ackerman and Associates carries an additional one million/three million liability policy
on the group and a general liability policy which meets the required criteria for this
application.
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; Susan Bromley, Psy. D., Licensed
Psychologist (and Licensed Social Worker); Emily Jaramillo M.A., L.P.C., Laurence P.
Kerrigan, Ph.D., Licensed Psychologist; Sherri Malloy (Gonzales), Ph.D., Licensed
Psychologist; Karen Bender, M.A., L.P.C. , Nicole Wamygora, M.A., L.P.C. and Cassie
Yackley, M.S. L.P.C.
C. Training The staff has extensive training in family therapy and short term therapy as
documented by their extensive work experience. Collectively, seven of the eight
providers have held licenses in their field for a collective total of more than 50 years
and an average length of holding the license of about 10 years. Resumes are
9
available upon request.
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. This proposal's
continuing education requirements coincide with the requirements of other
contractual arrangements and are being met on an ongoing basis by members of the
group.
E. Supervision Seven of the eight providers are independently licensed and not
required to have clinical supervision. One therapist , Emily Jaramillo-Bansberg, M.A.,
who is working toward liscensure, has recently completed supervision by Sherri
Malloy, Ph.D., a licensed psychologist in the practice as part of the requirement for the
LPC. All the staff have advanced skills in family therapy. The contract supervisor will
monitor the specifications made in this proposal.
F. Supervisor continuing education The supervisor of the project is involved in
ongoing training to keep current with her profession through advanced workshops
and seminars. Ackerman and Associates, P.C., of which the supervisor is the
president, has more than ten years contracting experience for major managed care
companies as short-term, solution-focused therapy providers in Weld County. By
contract, we have provided more than 1000 short term therapy sessions per year for
three of the last six years. Dr. Ackerman manages all short term solution focused
therapy contracts for Ackerman and Associates, P.C.
Unit of service rate computation
We have a usual rate for therapy services of$99.50 per hour. Since these are
consultation services, we are requesting a billing rate per hour of individual time of
$90 per hour for individual or couples consultation. Group services will be billed at
one half this rate per person as in these circumstances individual credits are being
given for continuing education. The overall profit margin for Ackerman and Associates,
P.C. for 1999 was 2. 9% of gross revenues. For 2000 no profit was generated as
reflected in profit sharing under a Type S corporate structure.
Budget Justification/Standards of responsibility for 2000-2001 bids
These rates are reasonable for providers of the licensed level and breadth of training
assembled in this proposal.
PAC money is tracked through a computer data base system that allows us to track
payments by client and by source of payment. All payment through the PAC will be
tracked in this manner. No special issues are presently related to project audit to our
knowledge and a random project audit for WCDSS have shown no discrepancies.
10
97O6/-/397
Audits will be conducted on a yearly basis.
Ackerman and Associates, P.C. is a type S professional corporation and not a 501.c.3.
Modifications to meet the bid requirements for 2000-2001 have been added as
follows and are reiterated in this years bid:
Standard of responsibility Ill D: The RFP reflects the precise number of sessions
needed to be effective, the number of sessions per week and the cost of each
session. For this program there are fifteen to twenty sessions on either an individual
or group basis. The cost of each session is $90 per individual or foster parent couple
hour. Group sessions can be substituted for individual sessions at $45 per group
hour. Two group hours is the equivalent of one individual/couple hour.
Standard of responsibility Ill E : The RFP must eliminate renewals or reduce the cost
of the renewal should it have to be reinstated. The mechanism to reduce renewals is
that we have established a 30 hour per foster parent maximum for all treatment of any
type. The only exception to this is in the two mandated training programs. These
renewals after 30 hours will require a second authorization from the program
supervisor after review of the progress of the case. A renewal will have a maximum
of ten hours of additional treatment provided. The only reason for acceptance of a
renewal is that the clinical supervisor believes additional hours will bring the foster
home to a status of compliance or the critical care needs of the child require ongoing
services .
Standard of responsibility III F: The RFP has a process for renewals sixty days ahead
of the program termination. A maximum of thirty hours of service will be set for each
foster parent in voluntary consultation. Only in mandated programs will this level be
exceeded using the mechanism in the paragraph above concerning renewals.
Standard of responsibility Ill G: The RFP reflects a maximum number of hours in three
stages of the program. We anticipate the average use of the program to be
approximately fifty hours per month. The pattern of use may not be even as the
workshops are not offered every week and tend to be most heavily attended in the fall
and spring with lowest attendance in the summer. It is unlikely the month to month
total will always be at fifty but should average around fifty. Regardless, the program is
capped at 750 hours of service, so no cost overrun for the year is possible.
As this is a new rule and its implications for monthly averages are unclear at this time,
we request a direct meeting with Social Services, in a timely manner, if there is any
concern in relation to this standard of responsibility in the next fiscal year. Thus, we
can remedy any potential concerns if they arise. For this program, the cumulative total
expended divided by the months of the program completed (the moving average)
would be the most useful measure of utilization in our opinion.
11
c9Dd/- /497
Standard of responsibility Ill H: The RFP requirement for a letter regarding carry over
into the 2000-2001 project period is acknowledged. Clients in individual consultation
who will carry over into this program will be reported at that time.
Standard of responsibility I is acknowledged. The case management plan will be
developed with the Foster Parent at their first meeting. A monthly report will be
provided giving times of contact but not content of information discussed. A final
narrative will be provided as to the fact the consultations occurred and the credits
earned. Content of the consultation is not designed to be shared with Social Services
except in mandatory training cases for corrective action.
12
aoz/- /397
Assessment Form
Workshop name
Workshop date
Workshop leader
Your name
1. The information you have learned through todays program for foster parents we
hope will help you meet the needs of your own biological children in adjusting or
coping with having foster children in your home.
For you, personally, in meeting the needs of your biological children, do you think the
information you have learned today will
a. help very much,
b. help somewhat,
c. help just a little,
d. not help but it won't make it more difficult,
e. not help and make it somewhat more difficult,
f. not help and make it much more difficult
g Not applicable because no biological children in the home
2. The information you have learned through todays program for foster parents might
help you meet the needs of the foster child(ren) in your home.
For you, personally, in meeting the needs of your foster child(ren) do you think the
information you have learned today will
a. help very much,
b. help somewhat,
e. help just a little,
d. not help but it won't make it more difficult,
e. not help and make it somewhat more difficult,
f. not help and make it much more difficult
Please provide any additional comments about the workshop in the space below.
Thank You.
13
074//-/399
Individual family consultation plan
Family Name
Consultant
1. What are three specific goals of this consultation?
1.
2.
3.
2.We will do the following to complete goal one.
3. We will do the following to complete goal two.
4. We will do the following to complete goal three.
At the outset of the consultation, ask the foster parent to list resources they know
about related to these three goals.
Are there issues of budgeting, purchasing, household maintenance or household
cleaning that will be addressed in this consultation. If so specify below.
Are there issues of parenting family dynamics, discipline, sibling rivalry, family
cooperation, specific behavior problems or other family concerns that will be
addressed in this consultation? Specify these below.
14
alai-/39/
For families in mandated corrective action, a formal assessment, the Mandated
issues report will be completed.
Family Progress Report for consultant's notes
Family Name
Consultant
Date of consultation
Progress toward mandated goal # 1
Plan for next
consultation
Progress toward mandated goal #2
Plan for next
consultation
Progress toward mandated goal #3
Plan for next
consultation
Notes:
15
calo/-/VV/
DECLARATIONS ❑❑TRUCK INSURANCE EXCHANGE XD FARMERS INSURANCE EXCHANGE O FIRE INSURANCE EXCHANGE
SPECIAL {AMU as
SENTINEL MEMBERS of FARMERS INSURANCE GROUP OF COMPANIES erunaa;r�
♦;LNO.P ••
PACKAGE HOME OFFICE: 4680 WILSHIRE BLVD.,LOS ANGELES,CALIFORNIA 90010
SUPER
Prod.
1. Named . DR JOYCE SHOHET ACKERMAN PC Count
Insured Prematic Acc't No.
. Mailing . 1750 25TH AVE SUITE 101
Address . 07-04-362 04576-38-07
GREELEY CO 80631 Agent Policy Number
Type of
The named insured is an individual unless otherwise stated: U Partnershl ® Corp. Business OFFICE
D Joint Venture LJ Organization(Other than Partnership or Joint Venture)
2. Policy Period from 07/01/00 (not prior to time applied for)
to 07/01/01 12:01 a.m.Standard Time.
If this policy replaces other coverages that end at noon standard time on the same day this policy begins,this policy will not take effect until the other
coverage ends. This policy will continue for successive policy periods as follows: 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,rules and forms then in effect.
3. Insured location same as mailing address unless otherwise stated: 1750 25TH AVE SUITE 101
GREELEY CO 80631
4. Mortgage Holders
Loan# Loan#
5. Premium$ 507.00 El "X"if Mortgage Holder Pays
6. Policy Forms and Endorsements attached at inception: 25-2880 E4103-ED2 565310-ED2 S0700-ED3
E6036-ED1 E4168-ED1 E4004-ED1 E4216-ED1 E3026-ED1
7. We provide insurance only for those coverages indicated by a specific limit or by an 111
COVERAGES LIMITS OF INSURANCE DEDUCTIBLE
A-Building $ $250 applies unless other
SECTION 1 B-Business Personal Property $ 52,000 o tlon IndlcatedS an®
wstoo❑$soo LJ$
C-Loss of Income(Not exceeding 12 consecutive months) ACTUAL LOSS SUSTAINED NONE
Property OPTIONAL COVERAGES
and Swimming Pool/Fences and Walkways $ Above deduc-$
Loss of 1r Building Glass(Blanket) REPLACEMENT COST tlbie applies $ 100
Income 'X Outdoor Sign Coverage $ 100 unless other $
Valuable Papers(In addition to$1000 included.) $ option Indi- $
cated.
❑ Earthquake Damage See Coverages 14
A,B,&C of the applicable ins.limit
SECTION II 0-Business Liability-Including Products and Completed LIMITS OF LIABILITY
Operations.(Annual aggregate applies for all occurrences (Annual Aggregate)
during the policy period.) $ 1,000,000
Liability E-Fire Legal Liability$75,000 included unless other option indicated by an
and ❑$100,000❑$150,000 each occurrence(Subject to the annual aggreagate shown for Cov.D)
Medicals F-Medical Payments to Others(Subject to the annual aggregate $5,000 each person
shown for Coverage 0.)
Limit of Liability
(Annual Aggregate)
❑Professional Liability(see attached endorsement) $
®I-V COVERED DEDUCTIBLE
SECTION III Agreement I-Employee Dishonesty $5,000 NONE
Agreement II-Broad Form Money and Securities-Inside $1 ,000 $250
Agreement III-Broad Form Money and Securities-Outside $1 ,000 $250
Crime Agreement IV-Medical Payments $500 each person NONE
Agreement V-Forgery or Alterations $2,500 NONE
58-51082-a2 2ND EDITION Countersigned ewit 12
Authorized Representative
61749-/-1S9
Attach..to your;policy with the'same number shown:on.this:endorsement:'. E4y0 '
• 2nd Edition
Named Insured• DR JOYCE SHOUT ACKERMAN PC • Agent Policy Number
Address• 1750 25TH AVE SUITE 101
• GREELEY CO 80631 07-04-362 04576-38-07
• of the Company
designated in the
Insured Declarations
Location
(Same as above unless otherwise stated here)
Effective Date 07/31/96 Limit of Liability$ 1,000,000 each occurrence .
$ 1,000 9000 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. 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 GRIEGO
PO BOX A
• GREELEY CO 80632
Countersigned
Authorized Representative • ;,
IPYMIP4
4P0UPt'
9',4103 2ND EDITION 6.95 1501 K-95 1501
ccoes/-/397
MEMORANDUM OF INSURANCE • Date Issued
05/24/2000
Insured This memorandum is issued as a
matter of information only and confers
ACKERMAN AND ASSOCIATES PC
no rights upon the holder. This
1750 25TH AVENUE
GREELEY Co 80631 memorandum does not amend, extend
or alter the coverages afforded by the
Certificate listed below.
Company Affording Coverage
Producer
Chicago Insurance Company
Kirke Van Orsdel
1776 West Lakes Parkway
West Des Moines, Iowa 50398 Covered Person (Status) Owner
x
Employee
JOYCE SHOHET ACKERMAN
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
Claims-Made 45P-2032570 05/01/2000 05/01/2001 annual aggregate $3,000,000
Covered Person's Retroactive Date: 05/01/1992
Should the above described Certificate be canceled Memorandum Holder
before the expiration date thereof, the issuing
company will endeavor to mail written notice to the
named Memorandum Holder, but failure to mail such GADR IAN
notice shall impose no obligation or liabilty of any PO BOX 172687
kind upon the company, its agents or representatives. DENVER CO 80217
Authorized Representative:
Jtv+-N a 4C,aa-r
6LR
d0�/_/39�
Issue Date: 12/01/00
<� 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 UTsyq(iyk�pri
Policy Number: CL10073401 Administered by: Alexandria,VA 22304-3300 TRUST
Toll Free:14300-347-6647 x284 ,...
ITEM DECLARATIONS INDIVIDUAL POLICY
1. NAMED INSURED: Norma Karen Bender
2 ADDRESS:
1104 Twin Peaks Circle
Longmont, CO 80503-2170
3. POLICY PERIOD: From: 02/04/01 To: 02/04/02
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 370 . 00
B. GENERAL LIABILITY S 0 , 00
TOTAL PREMIUM: S 3 70 . 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
delf:1/- /.397
Branch B/A Producer# Issue Date Renewal/Replacement No.
32 A 0002360 03/08/2001 RENEWAL
PSYCHOLOGISTS PROFESSIONAL LIABILITY
CLAIMS-MADE INSURANCE POLICY
PURCHASING GROUP POLICY NUMBER: 452-0002000
NOTICE: THIS IS A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY.
hem DECLARATIONS CERTIFICATE NUMBER: 45P- 2050203
NAMED INSURED: SUSAN FLOCK BROMLEY PSYD
ADDRESS 1621 13TH AVENUE
(Number & Street, Town, GREELEY CO 80631
County, State & Zip No.)
_ POLICY PERIOD: From 04/01/2001 To 04/01/2002
(12:01 A.M. Standard Time At Location Of Designated Premises)
COVERAGE: LIMITS OF LIABILITY PRE.\11Ly1
Professional Liability $1 ,000,000 $3,000,000 $802 . 00
each Incident Aggregate
4. BUSINESS OF THE INSURED: Psychology
THE NAMED INSURED IS:
( X ) Sole Proprietor (including Independent Contractors) ( ) Partnership ( ) Corporation
I 1 OTHER:
o. 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
This policy is made and accepted subject to the printed conditions of this policy together \\nit
the provisions, stipulations and agreements contained in the following form(s) or endorsemcn;t,i
PLu- 2008 ( 10/94 ) POE -8004 ( 5/88 ) PLE -2167 ( 07/00 ) PLE-2081
-P0N- 2003 PLE -8035 ( 09/97 )
CHICAGO INSURANCE COMPANY
55 E. MONROE STREET, CHICAGO, ILLINOIS 60603
REPRESENTATIVE: Agent or Broker: Kirke Van Orsdel
Office Address: 1776 West Lakes Parkway
Town and State: West Des Moines, IA. 50398
Toll-free Number: 1-800-852-9987
. . '' EKHATL
..... 'r:
\\( t
PLP-2C12 (06/93) (Elec.)
c,92YI/-/.3S�
PRIOR ACTS EXTENSION ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
In consideration of the premium charged for this policy, sub-paragraph B of Section I,
COVERAGE, is deleted in its entirety and replaced by:
B. At any time prior to the policy effective date shown on the Declarations if:
(1) Such act or omission happens on or subsequent to the "prior acts
date" listed below; and
(2) No Insured knew or could have reasonably foreseen that such act or
omission might be expected to be the basis of a Claim or suit on the
effective date of this policy or the first claims-made policy issued by
the Company to which this policy is a renewal, whichever is earlier
Prior Acts Date: 04/05/ 1996
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
crem:,um for this endorsement is included in the premium shown on Additional Premium $
aec'arauons unless a specific amount is shown here. Return Premium $
END0RSEMENT NO: Effective: 04/01 /2001
_ racnec !c and forms part of your evidence of insurance no.: 45P-2050203
Issued by: the Company named in the Declarations
Executive Offices: 55 E. Monroe Street
Chicago, Illinois 60603
s.,-ec SUSAN PLOCK BROMLEY PSYD
La's. ,ssJec Authorized Representative:
08. 2001 e
'Ec ' 0:931 (Elect (Real- /399
MEMORANDUM OF INSURANCE Date Issued
11/07/2000
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 11/01/2000 11/01/2001 3,000,000
in the aggregate
each incident
General Liability
or occurrence
Occurrence in the aggregate
Should the above described certificate be canceled Insured
before the expiration date thereof, the issuing
company will endeavor to mail written notice to the
named Memorandum Holder, but failure to mail such EMILY L 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:
, il/1+4/00 - A PSYCHOLOGISTS PROFESSIONAL LIABILITY POLICY
THIS IS A CLAIMS MADE POLICY-PLEASE READ CAREFULLY
*** RENEWAL ***
NOTICE: A LOWER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS
OF SEXUAL MISCONDUCT(SEE THE SPECIAL PROVISION "SEXUAL MISCONDUCT' IN THE POLICY).
DECLARATIONS
POLICYNO. 801-0005006 ACCOUNTNO: CO-KERL175-0 00997453
ITEM I. (al NAME AND ADDRESS OF INSURED: ITEM I. (b)ADDITIONAL NAMED INSUREDS: •
LAURENCE P. KERRIGAN,
PH . D.
1750 25TH AVE .
SUITE #101
GREELEY, CO 80631
•
TYPE OF ORG: INDIVIDUAL
ITEM ? ADDITIONAL INSUREDS:
ITEMS. POLICY PERIOD: FROM: 12/01/00 TO: 12/01/01
12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED H
ITEM 4 LIMITS OF LIABILITY: (a)$ EACH WRONGFUL ACTOR SERIES OF CONTINUC3 RI !' I
1 , 000 , 000 OR INTERRELATED WRONGFUL ACTS OR O('CI I:Rn. I
(b)$ 5 , 000 DEFENSE REIMBURSEMENT
(c)$ 3 , 000, 000 AGGREGATE
ITEM 5 PREMIUM SCHEDULE:
CLASSIFICATION NUMBER RATE ANNUAL PREMII \i
1ST PSYCHOLOGIST 1 1254 . 00 1 , 254 . 00
DEFENSE LIMIT 0?
SURPLUS LINES TAX 1 37 . 03
INSPECTION FEE 1 2 . 51 •
•
•
ITEM 6 RETROACTIVE DATE: 12/01/91 TOTAL PREMIUM: 1 , 294 . 13
ITEM EXTENDED REPORTING PERIOD
ADDITIONAL PREMIUM(if exercised):$ 2 , 265 . 24
ITEMS. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY
B22138 (7/95 ED. ) B22137
THIS IS NOT A BILL. PREMIUM HAS BEEN PAID. AUT RIZED COMPANY REPRE>FN \ !'\
Ar;22(10:9_) Americ Wnliasionut Agcna "+;If:u,ul
acl�i—/597
, . Branch B/A Producer# Issue Date Renewal/Replacement No.
32 A 0002360 02/29/2000 RENEWAL
PSYCHOLOGISTS PROFESSIONAL LIABILITY
CLAIMS-MADE INSURANCE POLICY
PURCHASING GROUP POLICY NUMBER: 452-0002000
NOTICE: THIS IS A CLAIMS-MADE POLICY, PLEASE READ THE POLICY CAREFULLY.
Item DECLARATIONS CERTIFICATE NUMBER: 45P- 2055185
1. NAMED INSURED: SHERRI MALLOY PHD
ADDRESS 24 ALLES DRIVE ;'j'„r
(Number & Street, Town, GREELEY CO 80631 '° -
County, State & Zip No.)
2. POLICY PERIOD: From 04/01/2000 To 04/01/2001
(12:01 A.M. Standard Time At Location Of Designated Premises)
3. COVERAGE: LIMITS OF LIABILITY PREMIUM
Professional Liability $1,000,000 $3,000,000 $598.00
each Incident Aggregate
4. BUSINESS OF THE INSURED: Psychology
5. THE NAMED INSURED IS:
( X ) Sole Proprietor (including Independent Contractors) ( ) Partnership ( ) Corporation
( ) OTHER:
6. This policy shall only apply to incidents which happen on or after: a) the policy effective
date shown on the Declarations; or b) the effective date of the earliest claims-made policy
issued by the Company to which this policy is a renewal; or c) the date specified in any
endorsement hereto. 04/01/1998
7. 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):
PLJ-2008 ( 10/94) POE-8004 PLE-2167 PLE-2081
PON-2003 PLE-8035 ( 09/97 )
CHICAGO INSURANCE COMPANY
55 E. MONROE STREET, CHICAGO, ILLINOIS 60603
REPRESENTATIVE: Agent or Broker: Kirke Van Orsdel
Office Address: 1776 West Lakes Parkway
Town and State: West Des Moines, IA. 50398
Toll-free Number: 1-800-852-9987
sitylmmem
INTERSTATE
INSURANCE
GROUP
PLR-2012 (06/93) (Elec.)
PLP-8003(7/94)(Ed. LASER)
07001-4697
- EVEREST NATIONAL INSURANCE COMPANY
MENTAL HEALTH PRACTITIONER'S
PROFESSIONAL LIABILITY POLICY
DECLARATIONS
Renewal of No. 2200009922-991
NOTICE: A SUB-LIMIT OF LIABILITY APPLIES TO "CLAIMS" ARISING OUT OF
"SEXUAL MISCONDUCT".
POLICY NO. 2200009922-001
ITEM 1: NAME AND ADDRESS OF INSURED: SEND ALL INQUIRIES TO:
Nicole R Warnygora nocgpopr INSURANCE ASSOCIATES
1800 Angelo Court PROGRAM ADMINISTRATOR
Fort Collins, CO 80528 R D BOX 1809
ROCKPORT, TX 78361-'809
1-800423.5344
ITEM 2: ADDITIONAL INSUREDS: NONE
ITEM 3: DESCRIPTION OF BUSINESS: MENTAL HEALTH PRACTITIONER.{SI
ITEM 4: POLICY PERIOD. FROM 05/20(2000 TO 05/20/2001
12:0` am STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN
•
ITEM 5: LIMITS OF LIABILITY: B 1,000,000 EACH WRONGFUL ACT OR EACH OCCURRENCE SU3JEC r -o A
•
$25,000 SUB-LIfAIT OF LIABILTY FOR ALL-WRONGFUL ACTS"
INVOLVING "SEXUAL MISCONDUCT".
$ 3,000 000 AGG9EGATE
ITEM 6: PREMIUM SCHEDULE:
CI ASSIFICATIDty N LMDIR BATE ANNUAL PREMIUM
CATEGORY M2 1 283.00 5 263.00
TOTAL PREMIUM $ 263.0D
ITEM 7: POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY:
190.00 0195, 189.00 0195, EEO 25 501 12 98, 193.00 0195
April 28, 2000 C
AUTHORIZED COMPANY REPRESENTATIVE
189.00 0195 m Everest National Insurance Company, 1996
hoar-i,69?
Issue Date: 09/08/00
�C 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 '(A•suL a
Policy Number: CL12494600 Administered by: Alexandria,VA 223047300 TRUST
Toll Free:1.800347.6647 x284
ITEM DECLARATIONS INDIVIDUAL POLICY
I. NAMED INSURED: Cathleen Yackley
2 ADDRESS:
1020 Wabash Street #6-203
Fort Collins, CO 80526-0000
POLICY PERIOD: From: 09/05/00 To: 09/05/01
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 395 . 00
B. GENERAL LIABILITY $ 0 . 00
TOTAL PREMIUM: $ 395 . 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
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 Iorm(s) or endorsement(s): CP1.0004.0199 CPL 0005 0199 CPL0006 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. aD c/_i39;
rot nnnc nano nn
AMERICAN FAMILY MUTUAL INSURANCE COMPANY
MADISON,WISCONSIN 53783-0001
PROOF OAF MOTOR VEHICLE
Policy No: 0869-0235-01-84-FPPA-CO
Eff Dab: 11-3-2000 Exp Data: 5-3-2001
1999 PONT GAS VIN: 1G2NE52E3XM811960
Coverages: BI-PD UM UIM COMP COLL PIP ERS
JARAMILLO, EMILY
183 50TH AVENUE PL
GREELEY CO 80634-4718
Agent: CHRISTINA GALINDO
Agent Phone: (970) 346-9356
COLORADO
INSURANCE CARD
INSURED KERRIGAN,LARRY P MUTL
POLICY NUMBER 2000862-D28.05B VO
YR 1988 MAKE HONDA 0FFECTI VE
MODEL ACCORD OCT 282000 APR 282001
VIN JHMCA5529JC11733q
AGENT RICK WALLACE
PHONE (970)356.82378237
1679-625
A BODILY INJURY/PROPERTY DAMAGE LIABILITY
P1 NO-FAULT
D COMPREHENSIVE
G 100 DEDUCT COLLISION
H,U
SEE REVERSE 910E FOR ADDITIONAL COVERAGE INFORMATION
COLORADO
INSURANCE CARD
INSURED BROMLEY,JOHN MUTL
VOL
POLICY NUMBER 653 7520-F07.08C EFFECTIVE
YR 1984 MAKE VOLVO DEC 072000 TO JUN 072001
MODEL 240 VIN YV1AXN55E1S83112
AGENT MARK LARSON
PHONE (970)355.8700
THE COVERAGE PROVIDED BY THE POLICY MEETS THE
MINIMUM LIABILITY UMITS PRESCRIBED BY LAW.
A BODILY INJURY/PROPERTY DAMAGE UABILITY
P3 NO FAULT•PPO(SLOAN'S LAKE)
D 50 DEDUCT COMPREHENSIVE
G 100 DEDUCT COLUSION
H,R1,U
SEE REVERSE SIDE FOR ADDITIONAL COVERAGE INFORMATION
c,71Y1/—/997
USAA CASUALTY INSURANCE COMPANY
IA Stock Insurance Company) sole D6 D7 Veh POLICY NUMBER
$fro 9800 Fredericksburg Road San Antonio, Texas 78288 CO D29b29 Tell 00211 02 59C 7103 5
COLORADO AUTO POLICY POLICY PERIOD: (12:01 A.M. standard time)
RENEWAL DECLARATIONS EFFECTIVE OCT 17 1999 TO APR 17 2000
(ATTACH TO PREVIOUS POLICY ) OPERATORS
amed Insured and Address 01 SHERRI R MALLOY-GONZALEZ
07 DAVID M GONZALEZ
SHERRI R MALLOY-GONZALEZ
24 ALLES DR
GREELEY CO 80631 -6829
VEH USE • WORK/SCHOOL
ascription of Vehiclels) Miles Days
H YEAR TRADE NAME MODEL BODY TYPE ANNUAL IDENTIFICATION NUMBER SYM Way Week
One Pe;
MILEAGE
6 94 HONDA CIVIC LX SED 4D 10000 1HGEG8666RL030869 11 W 02 3
7 99 TOYOTA SIENA LE/XLE WAG 4X2 5D 10000 4T3ZF13C9XU091812 15 P
•
PROO19EITfir
Insurance Identification Card- COLORADO
G California Casualty Name of Insurer:
IEbb.. PROGRESSIVE SPECIALTY INSURANCE COMPANY
CRN IA CASUALTY INDE ITT EXCHANGE
P.C. )9700 P.O. BOX 31557 C. BOX
COLOPAIr SPRINGS CO B0949-9700 TAMPA, FL 33631-3557
calcium Name of Insured:
EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE ALAN H ACKERMAN Effective Date:
01/08/01
INSURED: 1800 ANGE TCTD & NICOLE
1800 ANGELO cT Listed Drivers: Expiration FORT COLLINS CO 80528 JOYCE S ACKERMAN 01/06/02 Date:
RACHEL ACKERMAN
EFFECTIVE DATE EXPIRATION DATE POLICY NUMBER
08/09/00 08/09/01 102 2312594 -
YEAR MAKE/MODE1 VIN Policy Number: AA 70109900-0
99 TOYOTA TACOMA XCB 4TAWN72N9XZ569122
CLAIMS. 800-800-9410 SERVICE. 800-800-9410 Year Make/Model Vehicle Identification Number
� ���, 1992 HONDA 1HGCB7677NA196218
COLORADO pa NEW HAMPSHIRE
IN
SUI2ANCI; CARL) INSURED rAGKLINSURANCE CARD
INSURED BENDER,BRICE J 8 N KAREN BONNEMA,DOUG MUTL
MUTL POLICY NUMBER {011•F71 29A VOL
POLICY NUMBER CO54252-D14.0{G VOL YR 1998 MAKE HONDA EFFECTIVE
YR 2000 MAKE TOYOTA EFFECTIVE MODEL CIVIC DEC 112000 TO JUN ti 2001
MODEL AVALON OCT 14'2000 TO APR 142001 VIN 1HGEJ{1R0TL022250
VIN 4T10F28B{yU04{57{ AGENT RICH YACYSHYN
AGENT JEFF PFEIFFER PHONE (603)224.5298 2018-876
PHONE (303)651.0111
THE COVERAGE PROVIDED BY THE POLICY MEETS THE
MINIMUM LIABIIJTY LIMITS PRESCRIBED BY LAW, AB BODILY INJURY/PROPERTY DAMAGE LIABILITY
A BODILY INJURY/PROPERTY DAMAGE LIABILITY C MEDICAL PAYMENTS
P1 NO-FAULT D 50 DEDUCT COMPREHENSIVE
D 500 DEDUCT COMPREHENSIVE . 0 250 DEDUCT COLLISION
G 500 DEDUCT COLUSION - H,R1 U
Al,U •
SEiE REVERSE SIDE FOR ADDITIONAL COVERAGE INFORMATION
SEE REVERSE SIDE FOR ADDITIONAL COVERAGE INFORMATION
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