HomeMy WebLinkAbout20011418.tiff RESOLUTION
RE: APPROVE NOTIFICATION OF FINANCIAL ASSISTANCE AWARD FOR LIFE SKILLS
AND AUTHORIZE CHAIR TO SIGN -WELD COUNTY DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT
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 Life Skills between the County of Weld, State of Colorado, by and through the Board
of County Commissioners of Weld County, on behalf of the Department of Social Services, and
the Weld County Department of Public Health and Environment, 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 Life Skills between the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Department of Social
Services, and the Weld County Department of Public Health and Environment 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 C UNTY COMMISSIONERS
Ez�� WELD CO TY, COLORADO
ATTEST: Led, �1 ,
97 ft/4_2
Weld County Clerk to th-�:.. •;u;C• CCDttuuHHRP
/9hv1 Glenn Vaad, Pro-Tem
BY: .
Deputy Clerk to the Board /
WilliJerke ABPRO D A RP.4: u'pY\ E
Davi E. Long
unty Atto eyL
R bert D. Mas en
2001-1418
pe : 05' SS0028
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY,CO 80632
I WEBSITE:www.co.weld.co.us
C, Administration and Pub Assistance(970)352-1551
Ch
VI pild Support(970)352-6933
COLORADO
• MEMORANDUM
TO: M. J. Geile, Chair Date: May 23, 2001
Board of County Commissioners
FR: Judy Griego, Director a
Weld County Departm t of cial S is
RE: PY 2001-2002 Notification of Financial Assistance Awards (NOFAA) under Core
Services Funds-Weld County Department of Public Health and Environment
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.
Weld County Department of Public Health and Environment
Lifeskills. Service to a maximum of 25 families for six to eight months (24 to 32 weeks),
an average of one to two hours per week. Rate is$102.44/hour.
If you have any questions, please telephone me at extension 6510.
of
2001-1418
Weld County Department of Social Services
Notification of Financial Assistance Award
for Families,Youth and Children Commission (FYC)Funds
Type of Action Contract Award No.
X Initial Award FY01-PAC-8000
Revision (RFP-FYC-01005)
Contract Award Period Name and Address of Contractor
Beginning 06/01/2001 and Weld County Department of Public Health and Environment
Ending 05/31/2002 Life Skills
1555 N 17 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).
This program provides services to families whom The RFP specifies the scope of services and conditions
are experiencing difficulty with attachment and of award. Except where it is in conflict with this
bonding issues. A total of 25 family units will be NOFAA in which case the NOFAA governs, the RFP
served.Families would remain in the program for upon which this award is based is an integral part of the
six to eight months (24 to 32 weeks) initially, action.
based on DSS caseworker's referral and progress Special conditions
of the family. The average hours per week per 1) Reimbursement for the Unit of Services will be based
family would be one to two hours.A maximum of on an hourly rate per child or per family.
16 families served for 6-8 months(24-32 weeks), 2) The hourly rate will be paid for only direct face to face
an average of one-two hours per week. contact with the child and/or family, as evidenced by
client-signed verification form, and as specified in the
Cost Per Unit of Service unit of cost computation.
3) Unit of service costs cannot exceed the hourly and
Hourly Rate Per $ 102.44 yearly cost per child and/or family.
Unit of Service Based on Approved Plan 4) Payment will only be remitted on cases open with,and
referrals made by the Weld County Department of
Social Services.
Enclosures: 5) Requests for payment must be an original submitted to
X Signed RFP:Exhibit A the Weld County Department of Social Services by the
Supplemental Narrative to RFP: Exhibit B end of the 25th calendar day following the end of the
Recommendation(s) month of service. The provider must submit requests
for payment on forms approved by Weld County
Conditions of Approval Department of Social Services.
Approvals: Program Official:
By * Illy By
J
M. J. G ile, Chair Judy . Grie�, Direc r p
Board of Weld County Commissioners Wel ountyvvvvvvDepartment of Social Services
Date: O5/3.37.2noi Date: 5f23/0
caQo/- /51/Y
Signed RFP: Exhibit A
Weld County Department of Public Health & Environment
RFP: 01005-Lifeskills
INVITATION TO BID
RFP-FYC 01005
DATE:February 28, 2001 BID NO: RFP-FYC-01005
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-01005) for:Family Preservation Program--Life Skills Program Family
Issue's Cash Fund or Family Preservation Program
Funds
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 Life Skills Program must provide services that
focus on teaching life skills which are designed to improve household management competency, parental
competency, family conflict management and effectively accessing community resources. This program
announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date March 23, 2001 • I /
(After receipt of order) BID MUST BE SIGNED IN INK
MARK E. WALLACE
TYPED OR PRINTED SIGNATURE
Weld County Department of
Public Health & Environment 7`0Miliv 400.0 CUA
VENDOR
(Name) Handwritten Signature By Authorized
Officer or Agent of Vender
Director of Weld County Department of
ADDRESS 1555 N 17th Avenue TITLE Public Health and Environment
Greeley CO 80631 DATE March 71, 7001
PHONE# (970) 304-6420
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 32
RFP-FYC-01005 Attached A
LIFE SKILLS 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#RFP-FYC-01005
NAME OF AGENCY: Weld County Department of Public Health and Environment
_ADDRESS: 1555 N 17TH Avenue Greeley CO 80631
PHONE: ( 970 ) 304-6420
CONTACT PERSON: Rebecca McMahan. TITLE: Registered Nurse
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Life Skills Program Category must
provide services that focus on teaching life skills designed to facilitate implementation of the case plan by improving
household management competency.parental competency. family conflict management and effectively accessing
community resources
12-Month approximate Project Dates: 12-month contract with actual time lines of:
Start June 1. 2001 Start June 1, 2001
End May 31. 2002 End May 30, 2002
TITLE OF PROJECT: Identification and rasp management of families with attachment and
BUNT REQUES 1_D: bonding issues.
1 LPL U-9 — A N ,
Rebecca McMahan RN, BSN Child Health Program -0-3k-1D k ' (1
Name and Signature f Person Preparing D ument Date
Dr. Mark Wallace MD, Director 3/ 7-I I D
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
For both new bids and renewal bids,please initial to indicate that the following required sections are included in this
Proposal for Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund
Year 2000-2001 to Program Fund year 2001-2002.
Indicate No Change from FY 2000-2001 to 2001-2002
Project Description no
Target/Eligibility Populations no
Types of services Provided no
_ Measurable Outcomes no
Service Objectives no
Workload Standards no
Staff Qualifications no
Unit of Service Rate Computation yes
Program Capacity per Month no
Certificate of Insurance
Page 26 of 32
RFP-FYC-01005 Attached A
Date of Meeting(s)with Social Services Division Supervisor: )// 7/C I
CoRlments by SSD Supervisor: /VO I T o c-77-14-1 IA "t1--4-' ,
y r a q � � .1-13 Co
riAd RQVY1c,"---Jd // V/)
Name and Signature of SSD Supervisor Date
Page 27 of 32
Bonding and Attachment Intervention Program
I. Project Description
Definition:
Bonding is that emotional relationship between infant and mother which allows the child to
know basic trust and a sense of security. The child who experiences a strong nurturing bond with a
primary caretaker (ideally, the birth mother), will develop a sense of trust, good self esteem, and reciprocal
behavior with others. These are the tools that make it possible for her/him to form and maintain loving
lasting relationships in the future. Children who do not experience this nurturing, bonding behavior will
not learn to trust, will be insecure and will feel they do not belong. They tend to become controlling
and defiant in their behavior. They will be difficult for parents to manage. These are the babies who
resist cuddling, the children who are disruptive in the day care and class room and the teenagers who are
found in juvenile halls. They fail to develop a conscience and may develop poor impulse control,
learning disabilities, poor peer relationships, and lack of cause and effect thinking.
Precipitating Factors:
Children who experience separation, be it physical and/or emotional separation, from the birth
mother from conception through age two are at high risk for developing behavior patterns which impede
the child's ability to form lasting, meaningful relationships. Situations which contribute to this are
prenal influences such as substance abuse or a high level of stress he ta recurrent illness, hospitalization, abuse, during
negleect, and poor parenngt pregnancy.
slzills also have a negative e
birth
effect on the bonding process.
Intervention:
The purpose of this program is to provide support and information in order to assist parents in
establishing or rebuilding a broken bond with the child. Early intervention iisacrucial
f v to actor
working with children and parents in this area. As the child becomes older, he s more
learning trust. The goal of this program is to keep children with their biological parents when this is a
safe (both physically and emotionally) and healthy environment. The program could also assist
failed placements and frequent
adoptive/foster parents with the bonding process in order to eliminate
moves. The more often a child's placement is changed, the more difficult it is for her/him to learn to
trust the adults in his/her life and the higher the risk for the child of developing behavior issues related
to bonding.
Evaluation:
Symptoms of disruption in bonding and attachment occur on a continuum from mild to severe.
The public health nurse, who responds to the initial referral, will evaluate the child and parents for
evidence of bonding and attachment concerns. A community therapist will further evaluate children
who show evidence of more severe problems, with further consultation by a trained therapist as needed.
Becky McMahan, a public nurse with extensive experience in pediatric health care and Trish McClain, a
public health nurse with training in family development, will work closely with referred families. Dr.
Marilee Smith, a family therapist in our community who has experience working with children who have
attachment and bonding problems, will provide an evaluation and determine appropriate therapy for the
children and families referred to her. Margaret Meinecke, a therapist in private practice in the Denver
area, will provide consultation and evaluation as more complicated cases are referred to her. This family
centered collaborative model has been an effective tool over the past six years.
Direction and Closure:
An important part of the public health nurse evaluation is to identify the degree of bonding and
attachment issues of the child, level of parental frustration, and the strength and commitment of the
family. The public health nurse will work with the family in the home or at the site of the parent-child
visits for a period of time determined by the needs and progress of the family. Interventions will not
only be directed toward the parent-child interaction, but toward the individual needs of the parent and
child. Sessions will provide direction and closure around bonding issues. Ultimate closure is reached
when the parent/child relationship is reestablished, fears and insecurities diminish, and outside
assistance is no longer needed. The goal is for the child to return to or remain with the birth parent. If
this is not possible, a foster or adoptive parent can be assisted in a similar manner to address the
bonding issues of the child. The goal of this program is to assure that the child is in a placement which
is physically safe and emotionally healthy.
II. Target and Eligibility Population
Identification:
Services will be provided upon referral from the Department of Social Services (DSS) for
families who are experiencing difficulty with attachment and bonding issues. Children must be at risk
for being removed from the current home environment or at risk for continued placement outside of the
home. History of poor health, parental abuse, neglect, lack of parenting skills, substance abuse and
domestic violence all place children at high risk for attachment and bonding problems. Infants born
prematurely, and infants and children separated from their biological mother during the first twenty
four months of life are also at high risk for bonding issues.
Focus and Limitation:
A total of twenty five family units will be served throughout the fiscal year, with children's ages
being from birth to age six. These family units could include all family members who have a
relationship with the identified child. The family must be willing to invest in an ongoing relationship
with the public health nurse and be committed to improving the home environment for the safety and
emotional well being of the child. If the children are in foster placement, efforts will be made to work
with foster parents and biological parents to assist in reunification of families. We will assist in the
transition from foster to adoptive families to ensure that the placement will be successful.
Time Line Expectations:
Referrals for all Weld County families, regardless of geographic location, will be sewed. Weld
County's population includes a high number of monolingual Hispanic families. Children in these
families will be sewed through provision of an interpreter. Families will remain in the program for six
to eight months (twenty-four to thirty-two weeks) initially, based on DSS case worker's referral and
progress of the family. The family's progress and/or potential for progress will be evaluated at this time
by the bonding nurse to determine if additional services are warranted or feasible. The average hours per
week per family will be one or two hours. A family will begin with one to two hours of service per week
for the first three to four months. In the case that the family is progressing toward healthy goals, weekly
visits will be decreased to one hour per week or one hour biweekly for the remainder of the referral.
Client contact will decrease as the child and parent demonstrate a more bonded relationship. The
parent must show evidence that she/he is able to provide a safe, loving environment for the child.
The maximum number of families receiving intervention through home visitation will be no
more than ten per month. The monthly average home visitation capacity would be six to eight families.
A family could conceivably complete the program or be terminated early, depending on the individual
circumstances. A particular referral could be renewed if the family is working successfully toward
reconciliation and more time is needed to secure the family unit. This would be up to the discretion of
the bonding nurse, the therapist, the DSS case worker and family.
III. Services to Be Provided
Action Plan:
This program is designed to provide home visitation by a public health nurse (bonding nurse), in
order to assist the family with identification of their needs and to develop a plan with successful
outcomes. Although working in the home with families is the ideal, it is not always possible due to
placement of children outside the home. In this case we will work with parents and children at the
visitation site as arranged by the Department of Social Services case worker. Intervention includes
providing parents with information and support in their efforts to relate with their child. Through the
parent's increased knowledge and awareness of the importance of having a healthy bond with their child,
they will begin to better understand the parent-child relationship and its effect on their child's emotional
health and future success. The emotional status of parents is a key component to the success or failure
of this program. Parents may need a referral to other professionals or agencies to assist them with
addressing their own needs.
Skills Level Objectives:
During visits with the parent and child, the nurse will teach and model parenting techniques
which enhance bonding, such as, cuddling, rocking, making eye contact, playing interactively, reading
and talking appropriately to their child. These interactions are basic to rebuilding the broken bond
between the child and parent. Parents are also taught the types of discipline which are effective for a
child with bonding and attachment issues. The nurse works with the parent in the area of
understanding the developmental stages of their child and having appropriate expectations of the child.
This would include being able to anticipate behavior, providing play things for the child's age level and
using appropriate discipline. This is implemented by teaching, demonstration and positive coaching
techniques given by the public health nurse.
Goals:
Every day living skills are addressed per family assessment. Emphasis on providing a safe and
stable environment is important for families whose children have experienced some degree of insecurity
as a result of inadequate bonding. Consistency and routine in the household are extremely important
for these children. Parents may need assistance to stabilize their own lives before they can offer that to
the child. The intervention will include assistance in household management skills. This would include
information about food and nutrition, laundry, cleaning, hygiene, birth control, and money
management. A stable home environment is needed for these children in order to develop a sense of
trust and security.
Support Network:
Families will be assisted with referrals and information regarding other community agencies as
the need arises. Referrals range from medical issues to social concerns. Once families are
knowledgeable about community services, they will be encouraged to continue to access these agencies as
needed.
An Understanding:
Families receive ongoing evaluation to support and acknowledge their progress. The nurse and
the family will work together to identify family strengths and develop a plan for the family's involvement
in the program. The family is encouraged to identify and verbalize their concerns on an ongoing basis.
The nurse and the parent work together to establish goals. Parents receive ongoing verbal evaluation to
support and acknowledge their progress and to set new goals as needed. The family and nurse will
mutually agree when goals of the plan are met.
IV. Expected Measurable Outcomes
Screening the Child:
All families will be screened with a tool designed to indicate the presence and degree of bonding
and attachment. This screening identifies the problem behaviors of the child and gives an
indication of the parent's emotional status and degree of involvement with their child . (Copy attached)
By discussing the results of this screening, the nurse can assist families in identifying the needs of their
child. This discussion is helpful to the screener in determining the degree of commitment the parent
has toward the parent-child relationships, given the bonding nurse's insight into how best to work with
parents to improve parenting skills. The discussion may also open insights, improved understanding
and reassurance for the parent regarding their child's needs. This assessment will be completed
periodically through the referral period to measure the status of the family and will be shared
with the parents to assist in redefining goals. Results of the screening and ongoing assessments are
reviewed with the DSS caseworker on a consistent basis. Written monthly reports are also submitted by
the bonding nurse to the caseworker.
Screening the Family:
The Home Visit Risking tool will be used to identify problems in the home which relate to
safety, social and health concerns. This tool focuses on a wide variety of risk factors in every day living.
(Copy attached) The tool allows the public health nurse to develop a measurable plan in working with the
family. Concerns will be shared with the family arising from this assessment and include the family's
own perception of problem areas. This tool will be used to identify strengths in the family and to
develop a plan with them for improvement in specific areas. We will re-evaluate periodically with
parents to review progress and reappraise their concerns.
Outside Agency Support:
Parents are encouraged to work with community agencies to assist with their needs. The public
health nurse serves as a liaison between the family and the agencies involved. Successful experiences
and outcomes are measured by the family's commitment in keeping appointments, providing necessary
paperwork, and being responsible to the agency's requirements.
If, at the end of the referral time, the public health nurse does not see improvement in the
family situation, she will explore with the case worker and other involved professionals, other avenues of
service which might be helpful to the family. The public health nurse will make one phone contact with
the family three to six months after completion of the program to determine their current status.
V. Service Objectives
Periodic Review:
We would expect that parents would first come to understand the need to provide a safe, healthy
home environment for their children. Through direct modeling, providing information, improved
home interaction and, in some cases, referral to other community resources, we would expect to see
positive changes in the home. This will by monitored by observation and comparison to initial
concerns.
We hope to see an increased awareness of parents for the importance of bonding with their
children and the nurturing behavior required of them to ensure their child's sense of security. We expect
parents to come to a better understanding of the importance of being a nurturing parent. Through
educational literature, discussion, demonstration, we would expect to see an improved ability and effort
to provide a physically safe home environment with an emotionally secure parent-child connection. We
anticipate improvement in the parents' understanding of their child's needs and their response to those
needs. We also anticipate an improved ability to provide age appropriate interactive activities, with
limit setting, and healthy discipline measures appropriate for the age of the child. These activities would
be monitored and measured through observation of the nurse and parent input.
Using Resources:
Once we have introduced parents to available resources, we would expect parents to access these
resources to meet their needs. Experiencing trust and support through community resources is a
healthy step toward establishing family connectedness. After being assisted initially through this
program, the families may continue to access services independently as needed. Knowledge of the
correct phone calls to make and the necessary paper work to be completed, demonstrates the parents
progress. ( attainment of goals)
Empowerment:
An important goal of this program is to empower parents. Many parents who have children with
attachment or bonding issues feel isolated and angry. They may be angry at the children because they
are difficult to parent, or they may be angry with a system which may cause them to believe they are not
good parents. They may doubt their own ability to parent. By offering the tools of this program with
its positive support, we hope to see a parent with heightened self-esteem and a family with vibrant signs
of life and well-being.
VI. Workload Standards
A. Public health nurses will provide 64 hours per month of nurse time. Eight to ten hours per
month will be provided by a community therapist. Twelve hours of consultation time will be
provided over the course of the year by a private therapist.
B. The services will be provided by four individuals, two public health nurses, a community
therapist, and a consultant.
C. The public health nurses will be providing intervention for a maximum of 8-10 clients in a
month's duration.
D. The modality of treatment will be home visits (or at other locations as designated by DSS)
provided by the public health nurses one to two hours per week. Office visits will be the modality
of treatment for families referred to therapist. The consultation from the private therapist will
be available for the public health nurse, community therapist, and family as the need arises.
E. As A-D above.
F. As A-D above.
G. The caseload of the supervisor will not exceed that of the total caseload of the public health
nurses involved in this program.
H. Covered by county insurance—no copy attached.
VII. Staff Qualifications
Becky McMahan R.N., B.S.N.
Becky meets the educational requirements for nurses at the Weld County Health Department
with a Bachelor's degree in nursing. She has previous experience of fourteen years working in pediatric
nursing in the hospital setting. Becky has been with the Health Department for five and a half years.
She works with the Child Health Team with her primary focus being on the issues of bonding and
attachment. Becky has received training through workshops and inservices, numerous hours being
mentored by family therapists , and continues to keep abreast on current development related to the
field.
Trish McClain, R.N., B.S.N., B.A.
Trish has a Bachelor's degree in nursing and has been at the Weld County Health Department
since September, 2000. She also has a Bachelor's degree in Psychology which helps her to understand
family dynamics and contributes to her insight in working with parents and children. Trish completed
the orientation into the attachment and bonding program, has access to a wide array of resources and
has had mentoring with therapists in the field. Trish also works with children with special needs in
another program at the Health Department.
Cheryl Weinmeister, R.N., B.S.N.
Cheryl is the Child Health Supervisor since 1998, and has been at the Health Department since
1992. Cheryl's experience includes six years working with children who have special needs. Cheryl is
committed to the program's goals and objectives, and is aware of the time allotted to assure success.
Becky Cervantes, Interpreter
Becky is the interpreter and office technician for the program. She is bilingual and works in the
Child Heath Team. She assists with clerical duties for this program and is available to serve as an
interpreter when needed.
Dr. Marilee Smith Psy.D.
Marilee is a psychologist working in Weld County, treating adults, children and families. In
1997, she has received specialized training in the treatment of children with bonding and attachment
issues.
Margaret Meinecke L.C.S.W.
Margaret is a therapist in private practice. She has 11 years experience as a clinician with
families. Margaret also has extensive training and experience in working with children with bonding and
attachment issues.
CHILD'S NAME: DOB:
PERSON SCORING:
PROBLEM SEVERITY
SIGNS OF ATTACHMENT DISORDER
NONE MILD MODERATE SEVER`
* BIRTH TO ONE YEAR * (never) (25% of time) (50% of time) (75% or MD
Failure to respond with recognition to face of primary caretaker in first
6 months
" Infrequent vocalizations, i.e., babbling, crying
" Delayed milestones creeping, crawling, sitting
• Resistant to physical contact or appears stressed by it; rigid, unyielding
• Excessive fussiness, irritability
• Passive or withdrawn
" Poor muscle tone, flacid •
'ILL)'J IVHIVIt:
RSON SCORING:
SIGNS OF ATTACHMENT DISORDER PROBLEM SEVERITY
* ONE TO FIVE YEARS * NONE MILD MODERATE SEVERE
(never) (25% of time) (50% of time) (75%or more)
Excessively clingy, whiny
Persistent, frequent tantrums, sometimes escalating apparently beyond -
child's control
High threshold of discomfort. Seemingly oblivious to temperature
discomfort, may pick sores and scabs until bloody without manifesting pain.
Unable to occupy himself in a positive way without involving others
Resistant to being held
Demands affection in a controlling way on child's terms •
Intolerant of separation from primary caretakers except on child's terms
Intolerant of separation from primary caretakers except on child's terms
Indiscriminate displays of affection, sometimes to total strangers
Problems of speech development
Problems of motor coordination, may be considered accident prone
Hyperactivity evident
By five, may be manipulative, devious, destructive, hurtful to pets, •
frequently lying
Feeding problems
•
CHILD'S NAME: BIRTH DATE:
•
PERSON SCORING: •
•
SIGNS PROBLEM SEVERITY
NONE MILD MODERATE SEVERE
(never} (25% of the time} (50% of the time} (75% or more)
Lack of ability to give and receive affection.
(demands affection in a controlling way; abrupt,neutral,
unenthusiastic exchanges; absence of warm physical
contact; demanding and clingy)
Extreme control problems.
(persistent,frequent tantrums; hyperactivity evident)
Self-destructive behavior.
High threshold of discomfort.
(will not seek comfort if in pain)
Cruelty to others or animals.
(sadistic/violent; bullies,threatens,or intimidates; initiates
•
physical fights; has used a weapon)
Counterfeit emotionality.
(phoniness)
Stealing, hoarding, or gorging. •
(has broken into someone else's home,care,etc.; has stolen
items of non-trivial value; has stolen while confronting a
person,i.e.,mugging)
Speech pathology.
(problems of speech development)
Lack of long-term childhood friends.
Abnormalities in eye contact.
Sexual obsession.
(Has forced someorte into sexual activity)
Preoccupied with blood, fire, and gore.
(deliberately engaged in fire setting)
Superficial attractiveness and friendliness with
strangers.
(indiscriminate displays of affection)
Destruction of property.
Compulsive lying.
(devious; manipulative)
Defective conscience.
(no remorse) Difficult to observe.
Learning disorders.
Problems with motor coordination. •
P `
(may appear accident prone) .
•
Oppositional, resistant. defiant, and controlling
behavior.
Parents very frustrated or angry.
WINGS Attaclimenti
HOME VISITING - RISKING TOOL
Name D.O.D.
Score and date administered, please score on scale of 1-5 with 5 being the highest risk.
I ::!,ACTH VII COMMUNICATION
A. NO PRIMARY PHYSICIAN • A. LITERACY
B. UNINSURED 13. PRIMARY LANGUAGE
C. UNDERINSURED C. HEARING IMPAIRED
D.NO. OF HOSPITALIZATION D.HEARING
E .NO. OF DR. VISITS (over or under use) •
F. VISITS TO OTHER PROVIDERS (over or under use)
G. E.R. VISITS (for acute care non emergency.) IX ASSISSTANCE WITH ACTIVITIES OF
OF DALIY LIVING _
H ECONOMIC RISKS A. RESPITE
A. UNEMPLOYED 13. REHABILATION
B. HOMELESS 1. OCCUPATIONAL
C. INADEQUATE HOUSING(UNSAFE) 2. PHYSICAL
D. LOW INCOME 3. SPEECH
E. NUTRITION
F. CLOTHING X MEDICATION REVIEW
G. CHILD CARE
III VIOLENCE RISK XI LEGAL ISSUES
A. DOMESTIC VIOLENCE
B. ELDER VIOLENCE
C. CHILD ABUSE/NEGLECT XII EDUCATIOAL LEVEL
D. SEXUAL ASSAULT
F. GANG INVOLVEMENT
XII FAMILY STRUCRURE
IV MENTAL HEALTH CONCERNS A. SINGLE PARENT
A. GRIEF ASSISTANCE B. RUNAWAYS
B. VICTIM ASSISTANCE C. LIVING WITH NO PARENTS
C. ADDICTIONS D. TEEN PARENT
D. SUICIDE (PREVENTION/POSTVENTION)
E. DEPRESSION XIV DIAGNOSTIC CODE
V ISOLATION-GEOGRAPHIC
VI ENVIRONMENTAL RISKS
A. POTTERY
B. WATER
C. LEAD
ft RAW MILK
L AIR
I . C:I,I -I-I'EIZ - UNSANITARY CONDITIONS
RFP-FYC-01005 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-co-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 44 Hours [A]
Total Clients to be Served 25 Clients [B]
Total Hours of Direct Service for Year 1 , 100 Hours CC]
(Line [A] Multiplied by Line (B]
Cost per Hour of Direct Services $ 52.20 Per Hour [D]
Total Direct Service Costs $ 57,420.00 [E]
(Line [C] Multiplied by Line (D1 )
Administration Costs Allocable to Program $ 38,971.00 _ [F.]
Overhead Costs Allocable to Program $ 16,289.00 [G]
Total Cost, Direct and Allocated, of Program$ 112,680.00 [H]
Line [E] Plus Line [F] Plus Line [G] )
Anticipated Profits Contributed by this Program $ 0 (I]
Total Costs and Profits to be Covered
by this Program(Line [H] Plus Line [I] ) $ 112,680.00 [J]
Total Hours of Direct Service for Year 1100 [K]
(Must Equal Line (C1 )
Rate per Hour of Direct, Face-to-Face Service
to be Charged to Weld County Department of
Social Services $ 102.44 [L]
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