HomeMy WebLinkAbout991270.tiff RESOLUTION
RE: APPROVE FOUR NOTIFICATION OF FINANCIAL ASSISTANCE AWARDS FOR
CORE SERVICES FUNDS AND AUTHORIZE CHAIR TO SIGN - NORTH RANGE
BEHAVIORAL HEALTH
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with four Notification of Financial Assistance
Awards for Core Services Funds between the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld 'County, on behalf of the Department of
Social Services, and North Range Behavioral Health, commencing June 1, 1999, and ending
May 31, 2000, with further terms and conditions being as stated in said awards, and
WHEREAS, after review, the Board deems it advisable to approve said awards, copies
of which are attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, ex-officio Board of Social Services, that the four Notification of
Financial Assistance Awards for Core Services Funds between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Social Services, and North Range Behavioral Health, be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said awards.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 2nd day of June, A.D., 1999, nunc pro tunc June 1, 1999.
BOARD OF COUNTY COMMISSIONERS
JAI
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ATTEST: � �!
Weld County Clerk to t-- '=
'�� EXCUSED DATE OF SIGNING (AYE)
? :j Barbara J. Kirkmeyer, Pro-Tem
BY:
Deputy Clerk to the Bo EXCUSED D TE OF SIGNING _ (AYE)
George E. xter
AP OV TO FORM: _
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my Attorney
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991270
CC: Si SS0026
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DEPARTMENT OF SOCIAL SERVICES
i PO BOX A
GREELEY, CO 80632
CAdministration
and Public Assistance (970)352-1933Child Suppoe(970) 352-1551Protective and Youth Services (970)352-1923
COLORADO
MEMORANDUM
TO: Dale K. Hall, Chair Date: May 24, 1999
Board of County Commissioners
FR: Judy A. Griego, Director, and Social Services NO (#6It
RE: Core Services Notification of Financial Assist t4t0 Awards
between the Weld County Department of Social Services
and North Range Behavioral Health
Enclosed for Board approval is Core Services Notification of Financial Assistance
Awards (NOFFAs) between the Weld County Department of Social Services and North
Range Behavioral Health. The purposes of the NOFAAs are to conclude our Request for
Proposal Process for vendors under the Core Services Funds. The Families, Youth, and
Children(FYC) Commission has recommended approval of the NOFAAs.
1. The terms of the NOFAAs are from June 1, 1999 through May 31, 2000
2. The source of funds is Core Services, Family Issues Cash Fund. Social Services
agrees to pay North Range Behavioral Health unit costs as outlined in this
Memorandum.
3. North Range Behavioral Health will provide four programs to families and.
children in need of child protection services as follows:
• A. Day Treatment Program:
1) Description: The program provides mental health therapy and
education to children ages five to twelve. Day treatment will be
provided to an average of eight students monthly, 27.5 hours
weekly for 36 to 52 weeks.
2) Cost Per Unit of Service: $1,450 per month.
B. Sex Abuse Treatment:
1) Description: The program will serve sixteen families through at
least three hours weekly of home- and clinic-based mental health
services for up to 52 weeks.
2) Cost Per Unit of Service: $68.27 an hour.
991270
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C. Home-Based Intensive Family Intervention Program—Option B:
l) Description: The program will serve at least eight families
through three to five hours of weekly in-home mental health
services for up to nine months.
2) Cost Per Unit of Service: $68.27 an hour.
D. Intensive Family Therapy—Goal Achievement Program:
I) Description: The program offers an average of three hours
weekly of home- and clinic-based mental health services for up to
26 weeks to each family. The monthly program capacity is fifteen.
2) Cost Per Unit of Service: $68.27 an hour.
If you have any questions, please telephone me at extension 6510.
Weld County Department of Social Services
Notification of Financial Assistance Award
for Families,Youth and Children Commission(Core Funds)
Type of Action Contract Award No.
X Initial Award FY99-PAC-2004
Revision (RFP-FYC-99006)
Contract Award Period Name and Address of Contractor
Beginning 06/01/1999 and North Range Behavioral Health
Ending 05/31/2000 Carson Children's Center Day Treatment Program
1306 llth 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). The
A comprehensive,highly structured service alternative RFP specifies the scope of services and conditions of award.
to the out-of-home placement or the more intensive Except where it is in conflict with this NOFAA in which case
placement of a child (5-12 yrs) already in placement the NOFAA govems,the RFP upon which this award is based
that provides mental health therapy and education to its is an integral part of the action.
student clients. Twenty-four slots per year,a monthly
average capacity of 8 students,27.5 hours weekly for Special conditions
36-52 weeks.
1) Reimbursement for the Unit of Services will be based on a
Cost Per Unit of Service monthly rate per child or per family.
2) The monthly rate will be paid for only direct face to face
Monthly Rate Per $ 1,450.00 contact with the child and/or family,a.s evidenced by client-
Unit of Service Based on Approved Plan signed verification form, and as specified in the unit of cost
computation.
3) Unit of service costs cannot exceed the monthly and yearly
Enclosures: cost per child and/or family.
Signed RFP:Exhibit A 4) Payment will only be remitted on cases open with, and
Supplemental Narrative to RFP: Exhibit B referrals made by the Weld County Department of Social
Services.
VRecommendation(s)
5) Requests for payment must be an original submitted to the
Conditions of Approval 'Weld County Department of Social Services by the end of the
25'calendar day following the end of the month of service.
The provider must submit responses for payment on forms
approved by Weld County Department of Social Services.
Ap royals: Program Official:
gy By
Dale K.Hall,Chair Judy A, iego, irector
Board of Weld County Commissioners Weld C nty Department of Social Services
Date: �4.-/to o f q9 Date: _6 0 i f
p y /y
INVITATION TO BID
DATE: February 26, 1999 BID NO: RFP-FYC-99006
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-99006) for: Family Preservation Program--Day Treatment Program
Family Issues Cash Fund or Family Preservation Program
Funds
Deadline: March 23, 1999, 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,
1999, through May 31, 2000, at specific rates for different types of service, the county will authorize approved
vendors and rates for services only. The Day Treatment Program Category must provide a comprehensive, highly
structured program alternative to placement or more restrictive placement that provides therapy and education
for children. This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date
(After receipt of order) BID MUST BE SIGNED IN INK
Dale F. Peterson, M.S.W.. , M.H.A.
_ TYPED OR PRINTED SIGNATURE
VENDOR North Range Behavioral Health
(Name) Handwritten Signature By Authorized
Officer or Agent of Vender
ADDRESS 1306 11th Avenue TITLE Executive Director
Greeley, CO 80631 DATE 3/15/99
PHONE # (970) 353-3686
The above bid is subject to Terms and Conditions as attached hereto and incorporated
RFP-FYC-99006 Attached A
DAY TREATMENT PROGRAM BID PROPOSAL
FAMILY PRESERVATION PROGRAM
1999/2000 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 1999-2000
BID #RFP-FYC-99006
NAME OF AGENCY: North Range Behavioral Health
ADDRESS: 1306 11th Avenue Greeley, CO 80631
PHONE:f 970) 353-3686
CONTACT PERSON: Dan Dailey TITLE: Program Director
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Day Treatment Program CiJertonmuslvrovide
p comprehensive.highly structured program alternative to placement that provides therapy and education for children.
12-Month approximate Project Dates: 12-month contract with actual time lines of
Start June 1. 1999 Start
End M:y31. 1999 End -
TITLE OF PROJECT: Carson Children's Center
Dan E. Dailey, B.A. 3/15/99
Name and Signature of Person Preparing Docum 1 Date
Dale F. Peterson, M.S.W. , M.H.A. (149-V aae-_. 3/15/99
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REQUIREMENTS
Please initial to indicate that the following required sections are included in this proposal:
Indicate No Change from FY 1998-1999
C..' Project Description X
Target/Eligibility Populations X _.
IS. Types of services Provided X _.
t Measurable Outcomes K _
.'r Service Objectives Y _
' Workload Standards X _
„AP
E Staff Qualifications Y
r Unit of Service Rate Computation
r%? Program Capacity per Month
YIP Certificate of Insurance
RFP-FYC-99006 Attached A
Date of Meeting(s)with Social Services Division Supervisor: IVl A 2eiA (o (9 9 9
Comments by SSD Supervisor. -+t S r, if
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Name and Signature of SSD Supervisor Date
L PROJECT DESCRIPTION
In August 1995,Weld County School District Six(District 6), the University of Northern Colorado(U.N.C.), and
North Range Behavioral Health (N.RB.1L) (then the Weld Mental Health Center)jointly opened the Carson
Children's Center(C.C.C.)at 3807 Carson Street in Evans, Colorado. The C.C.C.is a year around day treatment
program for children aged five through 12 years. Licensed since October 1995, to provide services for up to 25
children,it currently has a capacity of 15 students,an increase of three over last fiscal year,due to space limitations
at its present site. This will change in Summer of 1999 when the C.C.C.will be programmatically and physically
integrated with the N.R.B.H. Children's Acute Treatment Unit at 2350 31"Street Road in Greeley. At that time,
the actual capacity may expand both the number of students and will expand the age range from five through 14
years.
Day treatment is a comprehensive,highly structured alternative to the out-of-home placement or the more intensive
placement of a child already in placement that provides mental health care and education to its student clients.
Treatment services for each clients family are an integral part of the program. At the C.C.C., day treatment
provides highly integrated and coordinated educational and treatment services to its students. The affective needs
of each child are responded to not only by the treatment staff but by the ednrstional and supportive services staffs
as well Similarly,the students'Miirations are not solely the responsibility of the teaching staff but are shared by
all on-site personnel. Because all C.C.C. students are staffed as special needs children,additional services called
for in each child's individualized education plans (IEP)such as occupational therapy, speech/language services,
and physical therapy are provided on-site.
The C.C.C.day begins with a welcoming group to greet the children and to help them make the transition from life
at home to a day in school and in treatment. Information from each students parents, guardians, or foster parents
is obtained directly or via notebooks sent home with and brought back each day by the students to keep the staff
and parents/guardians up-to-date and to encourage open communication. In the group room is a large bulletin
board with each students name and goals on which she or he is working. The goals and each child's progress
toward them are updated daily before the children move to other aspects of the day. Educational and affective
curricula are simultaneously in place as much as is feasible in the various daily activities. The students progress
through a series of treatment and educational offerings each day. While some children are in the classroom for
group or individual instruction, others are seen in individual therapy while others are in a treatment group. There
are ongoing,scheduled therapy groups that address new themes as well as themes from earlier sessions. The daily
schedule is similar from day to day promoting the consistent milieu essential to the children's success. Recess,
lunch, and other activities are similarly integrated_ The day ends back in the room where welcomes occurred.
Now, the focus is to review the day with the children and prepare them for the transition back to their homes.
Goals and successes of the day are the foci of this activity. One or more of the children may remain for a family
therapy session. Family therapy typically is planned for the end of the day to allow for parents'work schedules.
The schedule is sufficiently flexible to allow for such sessions during the school day as well.
Psychiatric services are integrated in the C.C.C. program. Farh child admitted is psychiatrically evaluated
including a determination of need for psychotropic medications. Follow-up psychiatric services are provided
throughout each student's stay and, when appropriate, in the care that follows treatment at C.C.C.
Students with special treatment needs have available to them the full array of services of N.R.D.H. in addition to
those available at C.C.C. Numerous students are seen in groups designed to help them deal with sexual abuse and
other trauma they have endured, to learn new ways to manage their anger, and to develop and refine their social
skills. Still other students may be residents of the Children's Acute Treatment Unit,returning there for residential
treatment services after each school day.
IL TARGET/ELIGIBILITY POPULATIONS
Once the new facility is opened,up to 24 children aged five through 14 years and their families may be
saved at any given time in the six to 24 month program of the C.C.C. Of these, it is anticipated that up
to eight could have the financial aspect of their care covered under the services proposed herein. Up to
40 children and their families will be saved annually of whom 12 to 14 will possibly be eligible for FYC-
funded services. It is anticipated that approximately 25%of all the students and/or their families will
require, and therefore receive, some level of bilingual/bicultural services on-site. Based on current
utilisation rates,it is estimated that up to 25%of the C.C.C. students will be from southern Weld County.
For the purposes of this grant,the monthly maximum program capacity is defined as eight children with
a monthly average program capacity of six. The average length of stay in the program is estimated to be
in the range of 36 to 52 weeks. Full-time students of the C.C.C. spend a minimum of 27.5 hours weekly
in the total program. In order for a child to be considered as a potential student of the C.C.C., she or he
must be staffed into special education services in her or his home school district and must have
demonstrated the capacity to return to her or his home school upon successful completion of the C.C.C.
program.
Children referred to the project will have met, or be at high risk to meet,the out-of-home placement
criteria detailed in the request for proposal. As mentioned above,each will also have met or be believed
to qualify for special education services.
ELL TYPE OF SERVICES TO BE PROVIDED
Site-based services to the students of the C.C.C.and their families will be held each day District 6 schools
are regularly in session plus through the summer. An academic year at the C.C.C. will consist of 46 total
weeks with an average of not less than 27.5 hours of programming weekly.
The planning and implementation of the C.C.C. have been a collaborative and cooperative effort from
its inception. The Weld County Department of Social Services (W.C.D.S.S.), involved early on in the
planning process, agreed to utilize the services of this day treatment program for those of its clients
demonstrating the need for it and for whom they believe they have financial responsibility. The
collaborative role of Weld County School District 6 has been exemplary from the planning stage forward
as it obtained and furnished the present C.C.C. site,recruited and hired professional and paraprofessional
staff, and provided administrative guidance. Early in the planning process, the District 6 Board of
Education expressed its eagerness to lead the way in this endeavor. District 6 has provided excellent staff
to aid in the planning and implementation of the C.C.C. primarily in the person of Mike Hoover,EdD.
Similarly, N.RB.H., with the strong support of its Board of Directors and management team offered
administrative assistance in planning and implementing the treatment program of the C.C.C. primarily
through Anne Mitchell,RN,JP-SW and Dan Dailey,BA. N.RB.H. hired additional staff to cover the
treatment nears of the children and their families. The U.N.C. has provided initial and ongoing technical
assistance through Teresa Bunsen, PhD from its Special. Education Department. The U.N.C. also
provides doctoral level students as part-time staff for the program, assisting primarily in the final and
transitional phase of the program when children are reintegrated into their home schools.
Extensive effort has been invested into planning the milieu and overall program of the C.C.C. so that
educational,therapeutic,behavioral,and recreational components are closely integrated. By design, each
of these four components contains aspects of the other three. Concerted efforts helped to achieve and
now serve to maintain this high level of integration. The educational component is primarily the
responsibility of the District 6 teaching staff plus other instructional staff as may be required. The
therapeutic component is primarily the responsibility of the N.RB.H. on-site staff. The behavioral
component of the C.C.C. is present across all activities of the program and is the responsibility of all on-
site personnel. Each student has an individualized efiination plan and a mental health services plan that
spell out educational,behavioral,and emotional concerns and detail how those concerns will be addressed
in the daily activities of the student. Similarly, the recreational component of the C.C.C. includes
educational,therapeutic,and behavioral programming to meet each student's needs. All components of
the program are typically carried out on-site. Exceptions to this occur primarily during times when a
student is in a transitional stage in returning to her or his home school and when off-site services, such as
involvement in a particular therapy group not offered on-site or in the summer gardening program, are
indicated.
Parents,guardians,and other caretakers are actively encouraged to be engaged in their children's education
and treatment whenever appropriate. Educational and support groups are offered to parents and siblings.
Family therapy sessions are held at least weekly for each student. In most instances, parental or guardian
involvement is mandatory. This stems from a core belief that not just the child but his or her family must
actively involve themselves in the treatment/education process for it to be effective and for the positive
results to be longstanding. The mental health services plan dictates the specific nature of the thmily work
that is required for each child.
The lead teacher at the C.C.C. is a certified special rtnration teacher for significantly identifiable
emotionally disturbed children. She is assisted by two full-time, specially trained pars-professionals in
carrying out each students individualized educational plan. It is anticipated the educational staff will
double in the new facility. Due to age of the C.C.C.'s students, there has been no need for vocational or
independent living assessment or training to date. This may change in the future if the C.C.C. moves to
accept students aged 15 years and older who will, of course, receive such services as part of the day
treatment program.
The mental health needs of the children are responded to by the N.R.B.H. on-site staff as described
above. Each student weekly receives up to two sessions of individual therapy, five sessions of group
therapy,and one session of family therapy. Those students with psychotropic medication needs are the
responsibility of the C.C.C. staff psychiatrist, currently Theron G. Sills, MD. For new students of the
C.C.C. who are not clients of N.RB.H. at the time of enrollment,an initial mental health assessment and
service plan is formidated. There is simultaneous development or updating ofthe individualized education
plan when a child is staffed into the C.C.C.
The physical health needs of C.C.C. students including but not limited to nutrition, medical, and dental,
are primarily the responsibility of District 6 nursing staff. These are shared as appropriate by the staff of
the C.C.C.
Proactive planning for reintegrating a student into her or his home school begins during the initial
screening of the child for consideration of admission to the C.C.C. The capacity to return to one's home
school, i.e., the school referring the child or the school the child will attend upon promotion to her or his
next higher grade,must be established before a child will be accepted into the C.C.C. program as must
be the referring school's willingness to have the student return there.
Similarly,the graduation requirements for students admitted to the C.C.C. are formulated in a preliminary
manner during the screening and planning sessions held with each child and her or his family, the staff
of the referring school,and social services caseworkers when appropriate. The requirements are largely
expressed in terms of outcomes the child will achieve. The program is constructed to emphasize the
positive outcomes and gains each student will make. Whenever possible, the strengths of the child will
be used as the primary tools for progress.
Follow-up mental health care for students graduating from the C.C.C. will be arranged by the C.C.C.
mental health staff with either N.RB.H., other mental health centers, or a private practitioner of the
graduate's family's or guardian's choosing. The transition plan that guides the student's return to her or
his own school also provides for a stepped,systematic introduction to the new therapist or reintroduction
to a previous therapist to ensure continuity from day treatment to more traditional outpatient services. In
some cases,children continue,while participating in day treatment,to see a therapist with whom they were
working prior to admission into the C.C.C.
•
IV. MEASURABLE OUTCOMES
Althe time of admission to the C.C.C.,each
Assessment/the
timeReportion(CCAR)developed.C. student will be evaluated using,in put,the Colorado Clinical
months thereafter and at discharge by the Colorado Office of Mental Health Services. Every six
form covers a wide range ofvria�bi sand assessmC. the ents The C.C.C. Admission and Termination
Evaluation F againAR will be administered. �three page
Forms are to be used as evaluation tools as well. These look s rminatthe
C.C.C.program. Copies of these forms are attached at the end of this specifically Al o attached
effects of thefrom evaluation of C.C.C. services in its first proposal. Also ahe styley are data
reporting and analyzing that are performed annually for the C.C.C. by the demonstrates B Program lu data
on
Office. Evaluation
It is anticipated that 90%of chew at en successfully
completing the program of the C.C.C. will reside in
their own homes,or
for the first six months after in pladisc similar level of care as they were at the time of their referral,
r
remains in her or his home or foster home and is able to safelyThe criteria for land constructively will tr that each child.returnse to e
first six months they are no longer attending . This information
will
doe go for at least the
hered by each
student's W.C.D.S.S. caseworker and mentl ealth therapist upon direct bservation of and interaction
with the child and her or his family.
Additionally,all successful graduates will enter,remain in,and make satisfactory progressin public school
after their discharge from the C.C.C. More specifically, each graduate of the C.C.C. will maintain or
enhance the progress she or he made academically,socially,behaviorally,and emotionally during her or
his time in the program. This will be monitored by the child's family,their W.C.D.S.S. caseworker, their
mental health therapist,and by the school/community facilitator(or the equivalent)from her or his home
school. The criteria for success will be maintenance of or improvement upon her or his levels of
functioning in the four areas mentioned above as stated in their individualized educational plan and their
mental health services plan.
The families of 90% of the children successfully completing the C.C.C. program will report a more
relaxed, nurturing, and competentrelaxed,
relationship with their children than existed prior to enrollment.
and six months thereafter. their W.C.D.S.S.caseworker and by their mental health therapist at discharge
Ninety percent of the children completing the C.C.C. program will report and demonstrate an improved
sense of self worth,self confidence and pride in themselves to their families, the C.C.C. educational and
mental health staff, and to their W.C.D.S.S. caseworker. Appropriate improvements will be revealed
when pre-C.C.C. CCAR ratings are compared with similar ratings done at the time of completed transition
back to the home school.
V. SERVICE OBJECTIVES
The primary goal of the C.C.C. is to successfully intervene in the lives of its students and their families
to minimize the figure need for similar intensive services,to enhance each child's ability to be educated
and to benefit from that education in her or his home school,to enhance each child's ability and capacity
to respond appropriately and healthfully to her or his family,and to improve each child's family's abilities
to adequately and appropriately respond to and provide for the child's needs in a competent, safe,
nurturing, and growth enhancing manner.
In working with families to achieve the goal of improving their abilities to manage family conflict in a safe,
constructive manner, the C.C.C. staff works toward the objective of resolving conflicts between the
parents and children so that no maltreatment of the children occurs, no domestic violence occurs, no
children run away from home,and no children commit status or legal offenses. Success is measured by
family,caseworker,and therapist reports that the objective was met. Each family will also be asked to
report on its subjective improvements in this area.
To meet the C.C.C. goal of improving overall parental competency,an objective of increasing the parents'
abilities to develop and maintain sound, caring,effective relationships with each other and with their
children is established An additional objective is to enhance the abilities of the parents to provide,with
as much proficiency as possible,for their family's care,nutrition,hygiene,discipline,protection,rib/ration,
and supervision. All parents are encouraged to develop appropriate support systems designed to last
beyond their child's involvement with the C.C.C. Again, the parents and children will be polled
concerning their subjective opinions about the improvements they have made as will the therapist and
caseworker.
The C.C.C. works with each client family to achieve the goal of improving its household management
competency. The objective is to enhance the capacity of the parents to provide a safe household
environment for the children through competently managing the home to include cleaning,repairing, and
maintaining the home, as well as via effective budgeting and purchasing. The family, therapist, and
caseworker will document the improvements made in this area.
The C.C.C. works to improve each family's ability to find and use appropriate resources. Treatment and
case management services assist each family to learn more effective means to obtain needed help from
other sources in the community and from local,state,and federal governments. This is modeled in each
of the families'relationships with the C.C.C. staff The families will report, and their caseworker and
therapist will confirm, all gains made in this area.
VL WORKLOAD STANDARDS
The C.C.C. will provide,at the start of the fiscal year,day treatment services to 15 children aged five
through 12 years, up to eight of whom will meet the FYC funding criteria. When the new facility is
opened,the capacity may increase to as many as 24 students ranging in age from five to 14 years. A year
round academidtreatment schedule is in place. It is anticipated that up to 40 children will be enrolled in
the course of a year. The average length of stay in the program will range from 36 to 52 school weeks.
Full-time C.C.C. students will attend an average of at least 5.5 hours of programming daily on all days the
school is in session. The total staff of the C.C.C. numbers more than 10 individuals, comprising slightly
more than the equivalent of six full-time employees. This staffing level excnds all Colorado licensing
rules. Said rules specify a student to total staff ratio of not more than eight to one which is far less than
the two to one ratio employed at the C.C.C. Even the ratio of on-site mental health staff to students(2.30
to 15)is well within the total staff ratio requirement. If there is a time when only one staff member is
present, a second staff member is on call and immediately available to be summoned to an emergency.
VH. STAFF QUALIFICATIONS
Licensing requirements mandate that day treatment programs have a treatment leader who is responsible
for the overall mental health services to each child. This person must hold a master's degree in the
behavioral sciences and have not less than five years of clinical experience. Counselors in day treatment
programs are mandated by the State of Colorado to have completed a bachelor's degree in the behavioral
sciences or to have at least four years of experience with appropriate aged children,and must be at least
21 years of age. Ginger Mcyctte,LCSW and Greg Schooley,MA are the current C.C.C.treatment leader
and counselor,respectively. Each fulfills the above requirements and has extensive experience in the field
of working with children and families. Ms. Meyette is a former classroom teacher who brings her
expertise in teaching and in mental health work to the C.C.C. She is bilingual English-Spanish. Mr.
Schooley brings more than two years experience in working with children. Additional therapists will be
added as necessary to maintain proper staffing ratios.
Anne Mitchell, RN, LCSW is the clinical supervisor for the staff of the C.C.C. and is its project
coordinator. She is responsible for attending screenings and stafiings of all children referred to the C.C.C.
Once a child is accepted into the C.C.C.,Ms. Mitchell assists the primary therapist in the development
of the day treatment services plan for him or her and for the child's family.
Dan Dailey,BA is the administrative supervisor of the C.C.C.'s mental health component. He is the also
the director of the Children's Acute Treatment Unit of N.R.B.H. He brings more than 28 years
experience in the mental health field to this task.
Theron G. (Ted) Sills, MD, staff psychiatrist for the C.C.C. is a board certified psychiatrist. He also
serves as the Medical Director of N.R.B.H. and, as such, is able to follow-up with children after they
graduate from the C.C.C. and enter more traditional outpatient care.
Mike Hoover,EdD is the administrative supervisor of the C.C.C.'s educational component. Since 1992,
he has been a Special Flh,eation Coordinator for District 6. Currently certified as a School Psychologist
and Special Education Administrator, he has worked in the field for more than 20 years.
The C.C.C.'s lead teacher,Gayle Schneider,MA, is a certified special education teacher for significantly
identifiable emotionally disturbed children and is also certified in the area of learning disabilities. She is
assisted by two full-time pan-professionals, Chris Basley and Kit Lynch, in carrying out each student's
individualized educational plan.
Ann Teague, RN and Nurse Practitioner, is the school nurse and health consultant to the C.C.C. She
regularly checks in with the staff and students of the C.C.C. and is also available as needed.
Providing additional services to the C.C.C. students are various U.N.C. Special Education Department
doctoral students. They assist in the classroom, therapy settings and also are working in the evaluation
aspect of the project. They are supervised by Teresa Bunsen, PhD who also serves as a consultant to the
C.C.C.
VIM PROGRAM CAPACITY BY MONTH
The C.C.C.is currently designed to function with a minimum clinical staff contingent of 2.001(1 h,serving
an average of 15 children and their families at any given time. At the present time,we are limited by our
current site to not accepting more than 15 children. This capacity may increase to up to 24 the end of
calendar 1999. The clinical staff will increase proportionately to the number of children enrolled.
RFP-FYC-99006 Attached A
VIII. COMPUTATION OF DIRECT SERVICE RATE
This form is to be used to provide detailed explanation of the hourly rate your
organization will charge the Core Services Program for the services offered in this
Request for Proposal. This rate may only be used to bill the Weld County Department of
Social Services for direct, face-to-face services provided to clients referred for
these services by the Department. Requests for payment based on units of service such
as telephone calls, no shows, travel time, mileage reimbursement, preparation,
documentation, and other costs not involving direct face-to-face services will not be
honored. Likewise, billings must be for hours of direct service to the client,
regardless of the number of staff involved in providing those services. Therefore, it
is imperative that this rate be sufficient to cover all costs associated with this
client, regardless of the number of staff involved in providing these services.
(Explanations for these Lines are Provided on the Following Page)
Total Hours of Direct Service per Client 517 Hours [A]
Total Clients to be Served 16 Clients [B]
Total Hours of Direct Service for Year 8,270 Hours [C]
(Line [A] Multiplied by Line [B]
Cost per Hour of Direct Services $ 11.49 Per Hour [D]
Total Direct Service Costs $ 95,000 _ [E]
(Line [C] Multiplied by Line [D] )
Administration Costs Allocable to Program $ 4,500 _ [F]
Overhead Costs Allocable to Program $ 9,500 _ [G]
Total Cost, Direct and Allocated, of Program$ 109,000 [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] ) $ 109,000 _ (J)
Total Hours of Direct Service for Year 8,270 _(K)
(Must Equal Line [C] ) ---
Rate per Hour of Direct, Face-to-Face Service
to be Charged to Weld County Department of
Social Services $ 13.18 [LtI
Day Treatment Programs Only:
Direct Service House Per Client Per Month 110 [M)
Monthly Direct Service Rate $ 1,450 _ [N]
1 AC N.
ORA. �+t�E �rE R
ne0oucl� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Flood & Peterson Ins . Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. O. BOX 578 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
4687 W. 18th Street COMPANIES AFFORDING COVERAGE
Greeley, CO 80632
COMPANY
ACNA Insurance
INSUREDANY
- ..
North Range Behavioral Health s
1306 llth Avenue
PANY
Greeley, CO 80631 C
O
I'
-COMPANY
I
COVERAGES I
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD i
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTNE POLICY EXPIRATION LIMITS
LIRDATE(MWODNY) DATE(MWDDNY)
A GFMFYAI uABIUW S182327225 01/01/99 01/01/00 GENERAL AGGREGATE e, 000, 000
X CONSAERCLAL GENERAL UADIUTY PRODUCTS-COMP/Op AGO S3 , 000, 000
CLAIMS MADE X OCCUR PERSONAL S ADV INJURY Sl, 0 0 0, 0 0 0
OWNER'S I CONTRACTOR'S PROT EACH OCCURRENCE 51, 000 L O 0 0
FIRE DAMAGE(My one Tire) 550> 00C_.
MED EXP(My one penal) 35, 0 0 0
A AUIOMOBILELIABILITY S182327225 01/01/99 01/01/00
ANY AUTO COMBINED SINGLE LIMIT $1, 000 , 000
ALL OWNED AUTOS BODILY INJURY 5
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY 5
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ J
ANY AUTO OTHER THAN AUTO ONLY: -
EACH ACCIDENT
AGGREGATE 5
A EXCESSUABBITY S182327225 01/01/99 0 1/0 1/0 0 EACH OCCURRENCE $2 _000 , 000
X UMBRELLA FORM AGGREGATE $2000 L 000
OTHER THAN UMBRELLA FORM S
WORKERS COMPENSATION AND STATUTORY LRAFTS
EMPLOYERS'LIABILITY
EACH ACCIDENT 5
THE PROPRIETOR/ _1 INCL DISEASE-POLICY LIMB
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $
IA OTHER Prof . Liab. S182327225 01/01/99 01/01/00 $1, 000 , 000 ea . pers .
Claims Made $3 , 000 , 000 total iimi
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
Retro date 7/1/86
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Weld County Placement EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Alternatives Committee 10 DAYS WRITTEN NONCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT
c/o Weld County, Department of BUT FAILURE TO MAIL SUCH NOTICE SHALLIMPOSE NO OBLIGATION OR LIABILITY
Social Security OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES
800 8th Avenue ALFR4ORRED REPRESENTATIVE
Oreeley, CO 80631 F/pod rt 1?e 'e4 o . lnSUAan.C!Q , Sna.-
ACdRp2b3 FPM WACORDCORPORAT7oN1983
l
I COLORADO CUENT ASSESSMENT RECORD
NAME: II IIGAF SCORE 1
ETHNIC/RACE 74 <s °•
I I 1 IAGENCY 14 I I I PROGRAM44 (1)American Indisn/Alasion Native
I 1 I I I I I I 1 ICLENT 1D sni (2)Asian/Pacific Islander
REFERRING AGY, (4)Hispanic
9LIEPTT ID lass (5)While(Non-HlspaNc)
Multi-Rectal
I I I. I I I I I I IMEDICAID ID xux HISPANIC ORIGIN n al
ADMISSION DATE»a0 (1)Not of Hispanic Origin
t
MONTH DAY YEAR (2)
(3)Puerto Rican
ACTION TYPE (Manual Input Only) 41-42 (4)Cuban
(5)Other Hispanic —
01=Admission 11=Correct on to Admission MARITAL.STATUS x I
02AActivate I2=Carecibn to Activation
03=Update 13=Correctlon to Update (1)Never Married (4)Widowed
04=Inacdvate 14=Carrectlon to Inactivation (2)Married (5)Divorced
05=Disdurge 15-Carodion to Discharge (3)Married Separated(Legal or Marital Discord)
06=Evaluatlon Only PLACE OF RESIDENCE n
I MEDS ONLY CUENT 43 (1)Correctional Facility/Jail
(1)Yes (Z)No ((3)Numing
ADMISSION STATUS 44 (4)Residential Facility-Mental Health
(1)New Admission (5)Residential Facility-Non-Mental Health
(6)Boarding Home
(2)Readmission From This Fiscal Year
(3)Readmission From Prior Fiscal Year (7)Homeless- Sr
HomelessO
(8) -On the Street
PERMANENT HANDICAP/IMPAIRMENT 4sas (9)Other Independent Living Arrangement
(Code N1,6 Barns llsirip 1 Yes 2 No) CURRENT LMNG ARRANGEMENT re
(1)Mental Retardation
(2)Deafness or Severe Hearing Loss (1)Lives With Both Parents
ParentOne
(3)Blindness or Severe Visual impairment (3)
Lives With
(3)Lives Wrth Spouse and or Other Relative(s)
(4)Speech Impairment (4)Uves Alone
(5)Non-Ambulatory or Assisted Ambulation (5)Lives With Unrelated Person(s)
LEGAL STATUS CURRENT EMPLOYMENT STATUS n
(1)Voluntary (1)Employed-Full Time
(3)Employed-Part Time
(2)Court-Directed Voluntary
(4)Homemaker-NotvA Othuse Employed
Forensic Involuntary
(4)72-Hour Evaluation and Treatment(MH-HOLD) (4)Shelteredin L or Force
(5)Short-Term Certified (5)Not m Labor Force
(6)Long-Tenn Certified (6)Unemployed For Less Months
thsn or3 Months
(7)Voluntary of Minors (7)UnemployedForcesFor 3 Months Duty)Muty
(8)Chadians'Code C.R.S.19-1-101
(8)Aimed (Active Military
(9)EmergAnvol At oholisnVDrug Conuhitrnert ANNUAL FAMILY HOUSEHOLD INCOME aoa4
t iic.. R 1-1-1 .EFERRAL SOURCE slat I
PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS NUMBER OF PERSONS SUPPORTED BY as
(a+Ppars °�
I l I I I I I I 1 11 1 THIS INCOME(Include Client)
I (1)1 (client only) (B)B
I PRESENTING PROBLEM HAS EXISTED hw (2)2 (7)7
(1)1 Year or Longer (2)Less Than 1 Year (4)4 (9)8
(4)4 (9)9 or More
PREVIOUS MENTAL HEALTH SERVICES ea-42 (5)5
. (Code elj Four Boxes Using 1 Yes 2 No) HIGHEST EDUCATION LEVEL-IN YEARS air
Inpatient Care (less Than First Grade Code n 00)
Other 24-Hour Care
Partial Care DUE TO MENTAL HEALTH REASONS, a
Care CLIENT IS CURRENTLY RECEIVING:
Outpatient (1)SSI (3)Both
I COUNTY OF RESIDENCE 1344 (2)SSDI (4)Neither
DATE OF BIRTH ssn FIRST 3 LETTERS OF CLIENTS LAST NAMEa++ I I
%..sWOt t ZIP CODE 0244 n-mo
MONTH DAY YEAR I-Ill_-I •I-- I I I
t'sEX n Triage Denver Health A Medical Center Only ton
(I)Maio (2)Female
•
I COLORADO CLIENT ASSESSMENT RECORD 2 1
Client I.D. Name Admit Date 1
HISTORY to2.10* Check ALL that Apply CURRENT PSEV Check ALL Problems that Apply
Vkl'Sead Abuse Hid:Suicide Attempt —Fid:Unstable Empbym MI AGGRESSIVENESS tH-tit
Vice Physical Abuse --H
id:Family Mentz
_VId:Neglect _Hid:Family Sub-Abuse _ g Out Threatening
Hos
SPECIALPROBLEMSASSUES nos-tts Check ALL that Apply — tile —leumwawq
Learning Disability CNS Disorder Language Issues pi ANn$OCIA4 196,203
L.oss/Grbf —Wetting/Soiling —Cultural/Bellet Issuesesped Disregards Rules Uses/Cons Others
—Eating Disorder _—Fin Set/Destroy Properly --Disobedient _Dishonest --
PROBLEM SEVERITY E] LEGAL 204210
_Legal Problems Probations/ParoleOffenses:Property
RATE the CURRENT PSEV(PROBLEM SEVERITY) _Charges Pending —_Offenses:Substances —Offenses:Persons
for area b the
Slight boxes provided,using the following scale: r-1 VIOLENCE/DANGER TO OTHERS 211-17
None Moderate Severe Extreme J
1 - 2 - 3 - 4 - 5 - 6 - 7 - B - 9 Violent Homicidal ideation
-Assault/ye —Homicidal ThreaVMempt
CURRENT P-SEV Check ALL Problems that Apply - aahemPhydSeemal Abuser Danger to e graltalia
EMOTIONAL WITHDRAWAL 117-t23 1—] FAMILY ISSUES 210.22e
—Distant
Passive _°octal Verbalize Feelings
Distant Subdued Blunted Med No Family/No Contact Family Legal Domestic Violence
—.Out _
of Home Placement Parenting Unstable NonlaFam
n DEPRESSION 12-13o — —
_Separation/Custody
Depressed Lonely Hopeless
— — — [1 FAMILY PROBLEMS WITH 226-231
Wornness Sad _Dejected J
Parent —Partner Relative
ANx1ET'' 131-139 _.Siding _Chita —
Anxious Nervous Panic
— [1 INTERPERSONAL PROBLEMS 232-its
Tense Flashbacks Phobic J
_Fearful _Nightmares/Terrors _w/Friend Establishing Relationships
HYPER AFFECT _.Social Skills _Maintaining Relationships
40-1K
—Overactive _Pressured Speech Elevated Mood 1—] ROLE PERFORMANCE(Work/School) 237-243
Mood Swings Accelerated Speech Mania
Absenteeism Performance Behavior
ATTENTION PROBLEMS 147-183 —
_Sucpensiort/PmWtion —Termination _Limited Employability
—Agitated Distractible _Mention Span in SUBSTANCE ABUSE 244.249
_Restless Impulsive Concentration
Problem w Alcohol Dependent/Addided In Recovery
nSUICIDE/DANGER TO SELF t ss-ta —'Problem wrags D —_Warferos with Responsibilities
—SucMs Ideation _S°U-Injury/Mul'lan°n 1 ] JJIEDICALIPHYSICAL zsazsc
Suicide Plan Sel
f-Endangerment
Self-Endaerment
Suicide Attempt Danger to Self 5i.RB."it*.-.7p}:::-: _Acute Illness Medical Can Needed Physical Handicap
Chronic Illness —InjuryByAbuse/Assaua —Permanent Disability
THOUGHT PROCESSES 161o1a
[] SECURITY/MANAGEMENT ISSUES 257-265
Bizarre Suspicious Repeated Thought
Delusions Paranoid Obsessive Seclusion/Time Out Watiaway/Escape Behavior Managemt
Hallucinations Close Supervision Security Suicide Watch
Medication Compliance Inadequate Mutt Supervision
COGNITIVE PROBLEMS tG117s — —
Confused Loose Associations Lacks Self Awareness OVERALL DEGREE OF PROBLEM SEVERITY 2s6
—Disoriented _Disorganized Impaired Judgement Check ONE Response
SELF-CARE/BASIC NEEDS i7l-/t3 None Slight Moderate Severe Eli erne
Hygiene DoesaWanage Money Doesn't Provide Food 1 2 3 4 5 6 7 8 9
Self Core Problems Doesn't Use Resources Doesn't Provide Housing
_°n.wl/Disabled (ORS3T g* UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL PROBLEM SEVERITY 2n
1 RESISTIVENESS 1*4110 Check ONE Response
Resistive EvasiveMuth
Wary Muth
ch lkcoopeative Guarded Denies Problems Better Better No Change Worse Worse
—1 2 a 4 5 —a 7 8 9
•
I COLORADO CLIENT ASSESSMENT RECORD 3
Client I.D. Name Admit Date
STRENGTHS/RESOURCES LEVEL-OF-FUNCTIONING (LOF)
Check ALL CURRENT STRENGTHS/RESOURCES MASS S hes: _ Check ONE Response for Each LOF Area
ECONOMIC RESOURCES 2111.27e SOCIETAL/ROLE FUNCTIONING 304
—MsdialdlAstsrs Employment _Transpormtlon Very High Moder High Average Moder Low Very Low
_OsarMedical inter —Housing Fulcctltan Furcticn Function Function Function_Other Public Assist Financial
1 2 3 4 5 6 7 9
EDUCATION I SKILL RESOURCES 27e-771
_targwps Skins _Merpersonal Skills Intelligence INTERPERSONAL FUNCTIONING sos
_Education _Job Millis — Very High Mode High Average Mader Low Very Low
PERSON RESOURCES Function Function Function Function Function
2eo-287 _
Partings) Partner Professionals Caregiver 1 2 3 5 6 7 8 9
Sthln g(s) ChUd(ren) _Other Supportive Relationship DAILY LIVING/PERSONAL CARE FUNCTIONING 30s
_RNatlw(s) _Fdad(s) Very High Mader High Average Mader Low Very Low
PERSONAL STRENGTHS 28ed01 Function Function Function Function Function
Li_ keableness —Emotional Stability _Adaptability 1 2 3 e 5 6 7 6 -Tr
Appeenance —Hadar _Thagld quay PHYSICAL FUNCTIONING
307
_Confidence Hopefulness _Resourcefulness
_
Judgement _Responsibility —Tolerance Very High Mader High Average Mader Low Very Low
Empathy Insight Function Function Function Function Function
1 2 3 s 5 6 7 g —9—
COGNITIVE/INTELLECTUAL FUNCTIONING we
Very High Moder High Average Moder Low Very Low
Function Function Function Function Function
1 2 3 4 5 6 7 g g
CURRENT OVERALL STRENGTHS/RESOURCES 302 OVERALL LEVEL OF FUNCTIONING Check ONE Response 309
Check ONE Response
Very High Moder High Average Moder Low Very Low
Very High High Moderate Some Very Low Function Function Function Function Function
1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
UPDATE.ACTIVATE,INACTIVATE&DISCHARGE ONLY UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL STRENGTHS/RESOURCES 303 CHANGE IN LEVEL OF FUNCTIONING Check ONE Response oat
Check ONE Response Much Much
Much Much Better Better No Change Worse Worse
Better Better No Change Worse Worse
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
I I I I I I _ I STAFF ID 311-311 STAFF SIGNATURE
ODISCIP s F' 1=none 2mnh worker 3=nursing 4-soctal work 5=psychology 6=psychiatry 7=other 320
pi DEGREE- 1=none 2 associate 3=bachdas 4=masters 5=PhD/PsyD/EdD 6=MD 7=other 121
COMPLETE THIS BOX ONLY FOR COMPLETE THIS BOX ONLY AT DISCHARGE
UPDATE, ACTIVATE AND INACTIVATE STATUS C- =7 DATE FORM COMPLETED
MONTH DAY YEAR 330437
C I EL] I ]LAST CONTACT DATE
MONTH DAY YEAR 338-Mi
EFFECTIVE DATE 322a29 f 1H r]F ]Q$CHARGLDATE
MONTH DAY YEAR MONTH
MONTH DAY YEAR 316JS3
C] TYPE OF TERMINATION 351
SPECIAL STUDIES 14Discharped7Translerred 5-From motive
2-TX Completed/No Referral 6-PatienVaient Died
a37Js4 3-TX CmMMMed/Fof en t/ow-up 7-Patient/CUM Terminated
MEvaluation Only
I-asTan
I I TERMINATION REFERRAL 3aaax
NOTE:Use 61 'Setr If no Referral
-
North Range
Behavioral Health
ludo O.Iu.
tiM1w ou y,1 J.
May 19, 1999
Judy A. Griego, Director
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
Re: RFP Recommendations and Conditions
Dear Ms. Griego:
The purpose of this letter is to respond to the recommendations and conditions specified in
your letter of May 14, 1999.
Intensive Family Therapy (RFP 99008)
1. Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (b)
Payment will be denied to IFT providers for any charges submitted foe therapy 45 minutes
or less unless cleared by explanation and approved by the program area supervisor.
NRBH Response: (a) IFT providers will receive further training and closer supervision, in
order to insure that quarterly reports are made in a timely manner. (b) This condition is
understood and it will be communicated to the appropriate IFT and billing personnel.
Option B (RFP 99010)
2. Recommendation: The program should be goal oriented. This program does receive
more than eight referrals a year.
NRBH Response: Close supervision will take place in order to insure that the program
remains oriented toward fulfilling the goals expressed in the proposal. The Option B
Program will be prepared to accept significantly more than eight referrals, as needed.
HI, ......... It I.-,. 1-(,ulu:al /017111 AS:1_ARM; / I k.0,01:L fi-ApIN:
Option B (RFP 99010) continued
2. Condition: Submit timely quarterly reports to caseworkers and offer more flexibility
with time frames for clients.
NRBH Response: Option B providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner. Additionally, closer
supervision and the further addition of potential providers will allow more time frame
flexibility.
Sex Abuse Treament (RFP 99007)
3. Recommendation: Submit timely quarterly reports to caseworkers.
NRBH Response: Treatment providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner.
Day Treatment (RFP 99006)
4. Recommendation: The caseworker shall be involved in the assessment process
NRBH Response: The is little doubt that the involvement of the caseworker is a necessity
in the assessment process. Closer supervision will occur to insure that greater alerts are
made to contact and communicate with caseworkers during tha assessment process.
If you have any further concerns or questions please let us know and we will address them
as quickly and effectively as possible.
Sincerely,
Cha s A. Howard, hP D.
Director of Children and Family Services
Dale F'. Peterson, M.S.W., M.H.A, Director
North Range Behavioral Health
10( vI1/ c
111( it' DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY, CO 80632
Administration and Public Assistance(970)352-1551
Child Support(970) 352-6933
O Protective and Youth Services(970)352-1923
COLORADO May 14, 1999
Mr. Dale Peterson, Director
North Range Behavioral Health, Inc.
1306 11 Avenue
Greeley, CO 80361
Dear Mr. Peterson:
Re: RFP 99008 (IFT) Intensive Family Therapy
RFP 99010 Option B
RFP 99007 Sex Abuse Treatment
RFP 99006 Day Treatment
Dear Mr. Peterson:
The purpose of this letter is to outline the results of the RFP Bid process for PY1999-2000 and to
request written information or confirmation from you by May 20, 1999.
A. Results of the RFP Bid Process for PY1999-2000
On April 7, 1999, the Families, Youth and Children (FYC) Commission approved the
RFP(s) listed above for inclusion on our vendor list. The FYC Commission attached the
following recommendations and/or conditions regarding your RFP bid(s).
1. RFP 99008, Intensive Family Therapy:
Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (b)
Payment will be denied to Intensive Family Therapy providers for any charges
submitted for therapy 45 minutes or less unless cleared by explanation and
approved by the program area supervisor.
2. RFP 99010, Option B:
Recommendation: The program should be goal oriented. This program does
receive more than eight referrals per program year.
Condition: Submit timely quarterly reports to caseworkers and offer more
flexibility with time frames for clients.
Page 2
North Range Behavioral Health/May 14, 1999
3. RFP 99007, Sex Abuse Treatment:
Recommendation: Submit timely quarterly reports to caseworkers.
4. RFP 99006, Day Treatment:
Recommendation: The caseworker shall be involved in the assessment process.
B. Required Response by RFP Bidders Concerning FYC Commission
Recommendations and Conditions.
The Weld County Department of Social Services is requesting your written response to
the FYC Commission's recommendations and conditions. Please respond in writing to
David Aldridge, Weld County Department of Social Services, P.O. Box A, Greeley, CO,
80632, by May 20, 1999, close of business, as follows:
1. FYC Commission Recommendations:
You are requested to review the FYC Commission recommendations and to::
a. accept the recommendation(s) as written by the FYC Commission; or
b. request alternatives to the FYC Commission's recommendation(s); or
c. not accept the recommendation(s) of the FYC Commission.
Please provide in writing how you will incorporate the recommendation(s) into your
bid. If you do not accept the recommendation, please provide written reasons why.
All approved recommendations under the NOFAA will be monitored and evaluated
by the FYC Commission.
2. FYC Commission Conditions:
All conditions will be incorporated as part of your RFP Bid and Notification of
Financial Assistance Award (NOFAA). If you do not accept the condition(s), you
will not be authorized as a vendor unless your mitigating circumstances are accepted
by the FYC Commission and the Weld County Department of Social Services. If you
do not accept the condition, you must provide in writing reasons why. A meeting will
be arranged to discuss your response. Your response to the above conditions will be
incorporated in the RFP Bid and Notification of Financial Assistance Award.
Page 3
North Range Behavioral Health/May 14, 1999
If you wish to arrange a meeting to discuss the above conditions and/or recommendations, please
do so through Elaine Furister, 352.1551, extension 6295, and one will be arranged prior to May
20, 1999.
Sincerely, a
J 1, A. 5nego, D recto
d County Department of Social Services
cc: Mike Hoover, Chair, FYC Commission
David Aldridge, Social Service Manager II
JG:ef
Weld County Department of Social Services
Notification of Financial Assistance Award
for Families,Youth and Children Commission (Core) Funds
Type of Action Contract Award No.
X Initial Award FY-99-PAC-14000
Revision (RFP-FYC-99007)
Contract Award Period Name and Address of Contractor
Beginning 06/01/1999 and North Range Behavioral Health-SAT
Ending 05/31/2000 1306 11 Avenue
Greeley, CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial Assistance
Award is based upon your Request for Proposal (RFP).
A maximum of 16 client families will be served. The RFP specifies the scope of services and conditions
Services provided include at least three hours weekly of of award. Except where it is in conflict with this
home- and clinic-based mental health services for up to NOFAA in which case the NOFA.A governs, the REP
52 weeks. upon which this award is based is an integral part of the
action.
Cost Per Unit of Service
Special conditions
Hourly Rate Per $ 68.27
Unit of Service Based on Approved Plan 1) Reimbursement for the Unit of Services will be based
on an hourly rate per child or per family.
Enclosures: 2) The hourly rate will be paid for only direct face to face
1 Signed RFP:Exhibit A contact with the child and/or family, as evidenced by
'Supplemental Narrative to RFP: Exhibit B client-signed verification form, and as specified in the
Recommendation(s) unit of cost computation.
Conditions of Approval 3) Unit of service costs cannot exceed the hourly and
yearly cost per child and/or family.
4) Payment will only be remitted on cases open with, and
referrals made by the Weld County Depattuient of
Social Services.
5) Requests for payment must be an original submitted to
the Weld County Depattuient of Social Services by the
end of the 25'1 calendar day following the end of the
month of service. The provider must submit requests
for payment on forms approved by Weld County
Department of Social Services.
App als: Program Official:
By � �. IAA --
Dale K. Hall, Chair Judy _ rieg irector
Board of Weld County Commissioners Weld .ount Department of Social Services
Date: CL/e2,2/9 y Date: J 04. ef
- —
INVITATION TO BID
RFP-FYC 99007
DATE: February 26, 1999 BID NO: RFP-FYC-99007
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-99007) for: Family Preservation Program--Sexual Abuse Treatment
Program Family Issues Cash Fund or Family Preservation
Program Funds
Deadline: March 23, 1999, Tuesday, 10:00 a.m.
The Families, Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that competing applications will be accepted for approved vendors pursuant to the
Board of Weld County Commissioners' authority under the 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, 1999, through May 31, 2000, at specific rates for different types of service, the
County will authorize approved vendors and rates for services only. The Sexual Abuse Treatment Program
must provide for therapeutic intervention through one or more modalities to prevent further sexual abuse
perpetration or victimization. This program announcement consists of five parts, as follows:
PART A...Administrative Information PART I)...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date
(After receipt of order) BID MUST BE SIGNED 1N I[NK
Dale F. Peterson, M.S.W., , M.H.A.
TYPED OR PRINTED SIGNATURE
VENDOR North Range Behavioral Health ak. aStitLei
(Name) Handwritten Signature By Authorized
Officer or Agent of Vender
ADDRESS 1306 llth Avenue TITLE Executive Director
Greeley, CO 80631 DATE 3/10/99
PHONE # (970) 353-3686
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 35
•
RFP-FYC-99007 Attached A
SEXUAL ABUSE TREATMENT PROGRAM BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING
FAMILY PRESERVATION PROGRAM
1999/2000 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 1999-2000
BID#RFP-FYC-99007
NAME OF AGENCY: North Range Behavioral Health
ADDRESS: 1306 11th Avenue Greeley, CO 80631
PHONE:f 9701 353-3686
CONTACT PERSON: Patricia Orleans ,L.C.S.W. TITLE: Director of Children & Family
Services
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Sexual Abuse Treatment Program mu,t
provide for therapeutic intervention through one or more modalities to prevent further sexual abuse pe netration or victimization.
12-Month approximate Project Dates: _ 12-month contract with actual time lines of:
Start June 1. 1999 Start
End May 31,2000 End
TITLE OF PROJECT: Sexual Abuse Treatment
AMOUNT REQUESTED: N/A
Patricia Orleans , L.C.S. ` �.j�2 - .3_,n -99
Name and Signature of Person Prepay✓ument Date
Dale F. Peterson, M.S.W. , M.H.A. \I Ir-t, �� 3 -/o - fl
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REOUIREMENTS
For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for
Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 1998-1999 to
Program Fund year 1999-2000.
Indicate No Change from FY 1998-1999
Project Description C 27
Target/Eligibility Populations
ypes of services Provided 'It-2
feasurable Outcomes
9 ervice Objectives
_,. orkload Standards _
a:tail Qualifications r
�A nit of Service Rate Computation
P rogram Capacity per Month _ )
S+% ertificate of Insurance
Page 29 of 35
a sima;
RFP-FYC-99007 Attached A
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Date of Meeting(s)with Social Services Division Supervisor: CA.P S fo / 3 /o- 9,
Comments by SSD Supervisor: L 7 7a y ��7
•
3/1-0 fr
Name and Signature of SSD Supervisor Date
Dan. WI nfzc
RFP FYC-99007
Sexual Abase Treatment
North Range Behavioral Health
L PROJECT DESCRIPTION
The Sexual Abuse Treatment(SAT)service of North Range Behavioral Health(N.ltB.H.),formerly the Weld
Mental Health Center,saves child and adolescent victims and perpetrators of sexual assault as well as,when
appropriate,the adult family members who are perpetrators of sexual assault. It is the most intensive outpatient
offering of N.R_B.H. dealing with the sexual abuse of children and the only one of the Family Preservation
Team's(FP1)services designed specifically to do so. Its services focus on family strengths and include work
in the areas of problcan solving techniques, child management practices, stress management techniques,and
the appropriate use of available resources and support systems. The therapy provided by the SAT is designed
to address issues and behaviors related to sexual abuse victimization, sexual dysfunction, and sexual abuse
perpetration. Its quest is to prevent additional episodes of sexual abuse and to allow all those affected by the
abuse the opportunity to recover. We seek to be able to offer this service to at least 16 families at any given
time who need, in the assessment of their Weld County Department of Social Services (W.C.D.S.S.)
caseworker,this type of mental health intervention. We will accept as many families into the SAT services as
the community needs served. The SAT offers an average of at least three hours weekly of home-and clinic-
based mental health services for up to 52 weeks to each client family. If a family needs an extended period
of similar services to reach its objectives,a 26-week extension,if approved,may be provided at the same level
of care. The actual extension will be jointly agreed upon by the family,the SAT therapist, and the W.C.D.S.S.
caseworker pending approval of the plan by a W.C.D.S.S. internal agency review and by W.C.D.S.S.
administration. The W.C.D.S.S.caseworker will document the reason for extension in the family's case record.
Four primary types of treatment services are provided to recipients of SAT services: therapeutic, concrete,
collateral,and crisis intervention. Each family admitted to the project will have a service plan developed for
it that spells out the specific services to be delivered in each of these four categories. The plan describes how
a child and his or her family will be treated in order to rapidly respond to and remedy the sexually abusive
situation in the family that presents the risk of an ont-of-home placement of a child rimming or that precludes
the safe return of a child already in placement. Evaluations necessary to the establishment of these plans are
an integral part of the service.
The SAT services will concentrate on a series of service objectives in our efforts to achieve the goal of safely
maintaining a child in her or his home or of safely returning the child home. These objectives are to improve
the family's ability to resolve and manage conflicts within the family, to improve parental competency, to
improve the household's management competency,and to improve the family's ability to gain access to needed
resources.
SAT services will take on different configurations based on the needs of each of the client families. Extensive
family work will be at the core of each configuration. Group therapies for the victims and the perpetrators of
sexual violence will figure extensively into the design as well,the actual types determined by the specific issues
each client family brings to their treatment. Plethysmographic and polygraphic assessments are available as
a part of the offense specific sexual offender aspect of this service when appropriate.
IL TARGET ELIGIBILITY POPULATIONS
The design of SAT services is to serve at least 16 families with an average monthly capacity of 12 families.
N.R E.IL will,however,accept an unlimited number of families into this project The average length of stay
will be 52 weeks for families not needing extensions of the initial treatment period and 78 weeks for those who
do need extensions. Families will be provided a minimum of three hours of care weekly, the actual
composition of which will be determined on a family by family basis through negotiation with the W.C.D.S.S.
caseworker. All families will have access to emergency services 24 hours a day, seven days a week. Referred
children may range in age from birth through 17 years. Offense specific, sexual offender treatment for
adolescents and adults can be an integral pad of the services when indicated. Adult sexual assault perpetrators
who do not receive offense specific treatment services within this project will be provided family services upon
being deemed appropriate to be included by the therapist(s)treating them and upon consultation between the
SAT therapist and W.C.D.S.S.caseworker.Nuclear family members of the referred child and members of the
extended family deemed necessary will be included in the treatment process. At least one parent/guardian must
consent to work with SAT toward the goal of maintaining or ramifying the family. It is anticipated that up to
25%of the client families may require,and will therefore receive,bicultural and/or bilingual services. Care
will be available throughout Weld County with at least 25%of the client families anticipated to be residing
in southern Weld County. Families will have demonstrated a reasonable possibility that services will bring
about sufficient improvement in child and family functioning to allow a child to safely reside in or return to
ha or his home. A manageable level of risk that further sexual abuse perpetration or victimization in the family
and in the community will not occur must be present. A child in placement must be able to be returned home
within six months of the start of SAT services. Children refeaed to the project will have met or be at high risk
to meet the out-of-home placement criteria outlined in the request for proposals.
IIL TYPE OF SERVICES TO BE PROVIDED
All families referred to and accepted into the SAT project will receive home-and/or clinic-based services for
not less than three hours weekly for up to 52 weeks. Those families deemed to be in need of continuing SAT
services beyond the initial 52 weeks and approved for such as outlined above will receive services for an
additional 26 weeks. SAT offerings, consisting of therapeutic, concrete, collateral, and crisis intervention
services,may include services provided by staff members of Individual and Group Therapy Services(IGTS)in
addition to those provided directly by N.R.B.H. All services are delineated in a comprehensive service plan
tailored to the specific needs of each client family,designed with the collaboration of the client family and its
W.C.D.S.S. caseworker. This plan is a dynamic document, changing to fit the needs of the family and its
members.The therapeutic services include,when appropriate,individual,group, and family therapy, support
groups,education in problem solving lessons in communication skills, and training in parent-child and parent-
parent conflict management. Group treatment for parents of abused children, for the abused children
themselves, for child, adolescent, and adult perpetrators of sexual violence, for parents of those sexually
violent members of the family,and for the not abused siblings of an abused child will be available as needed
in the course of SAT services as will be mixed family therapy groups for youthful perpetrators and their
parents. For perpetrators of sexual violence,recidivism prevention treatment will be in place as well.
Access to polygraphic and penile plethysmographic(PPG)assessments is built into this service. These are
highly specialized, state of the art tools to ensure that sexual offenders are benefitting from the treatment
offered them. Joint agreement between the W.C.D.S.S. and N.R.B.IL workers will precede the use of these
assessments.
Psychiatric services including evaluation and the prescribing and monitoring of psychotropic medications are
available to each of the client families as are psychological services such as psychological testing and
evaluation. Access to such services will be based on the family's needs and on an agreement between the
W.C.D.S.S. caseworker and the SAT mental health worker that the services are necessary to fulfill the
treatment plans that are in effect.
Concrete services will include,but not be limited to,training in the development and enhancement of parenting
skills, stress management and reduction, problem solving, anger and impulse control, budget and general
household management,and the planning of family activities and recreation_ Collateral services will focus on
preparing and teaching finales to gain access to and work constructively with other community agencies whose
services would benefit them. Crisis intervention services,whether provided in the family's home, in the child's
school, in the mental health or other clinic, in other settings, or over the phone, will be available on a
continual,24 hour basis. Up to 1.5 hours of case management services will be provided weekly to each family.
Upon receipt of a referral,the SAT staff will contact the referring W.C.D.S.S. caseworker to begin the service
planning process including the study of all pertinent information about the family. Together, they will
establish a plan to introduce the assigned therapist to the family and ensure that the family understands the
nature and intent of the SAT service and agrees to participate in it. Family members will be advised of their
rights in receiving mental health services,of the obligations the assigned therapist has in regard to them, and
of the credentials of the assigned therapist. The services to the family will start at the first opportunity.
Initially,the SAT therapist works with the family to assess its strengths and weaknesses. Of focal concern in
this process is the establishment of a system to ensure the safety from abuse of client children. Based on this
assessment, the service plan, emphasizing the family's strengths, will be further developed and initially
implemented Appropriate releases of information will be obtained to permit the flow of information between
those agencies and individuals with whom the family already interacts and with those whose services the family
will need
Delivery of the core services outlined above will maintain the emphasis on the strengths of the family while
closely monitoring the safety of the at risk child(ren).Each member of the family is engaged at an appropriate
level given her or his position in the family. Not only are the collective strengths of the family shored up,the
individual strengths of each family member me studied,enhanced,and utilized in such a manner as to improve
the life situation of each member and the family as a whole.
As the ability of the family to provide safety and security for its members is enhanced, the service plan is
updated to secure the gains made to date,evaluate what is working and what is not working,and to generally
improve the family's capacity to effectively handle the crisis that lead to the initial referral and to generalize
that improvement in the family's general level of functioning.
Case management services consisting of referral,linkage,monitoring, advocacy, and service planning will be
utilized to maximize each client family's ability to benefit from treatment and to ensure that each family has
access to and receives appropriate services from other agencies.
The SAT services are culturally sensitive and competent.They are designed to be consistent with the culture
and belief systems of the client families. Training to educate and sensitize our staff to the needs and cultural
differences of the residents of Weld County occurs on a regular basis.
Daring the evaluation of sexual perpetrators,a variety of tests are used. Primary tests used with adults,if their
reading and comprehension are above the 6th grade level,are:
Minnesota Multiphasic Personality Inventory-II(MMPI-II)
Multiphasic Sexual Inventory(MSI) Sex Offender Specific Polygraphs
Hare Psychopathy Checklist-Revised(PCLR) Able Becker Cognition Scale
Beck Depression Inventory Attitudes Toward Women Scale
Wilson Sexual Fantasy Questionnaire IGTS Offender History Questionnaire
Sone Sexual History IGTS Forensic Interview
Child Molester Scale(CHI-MO) Expulsion/Regression Scale
Sexual Social Desirability Scale(SSDS) Domestic Violence Inventory
Empathy Scale(Empat) Penile Plethysmograph
These tests are used in conjunction with one or more clinical interviews and with the study of any collateral
information that has been received. Most reports from our agencies have between four and six different tests
used in supporting each recommendation.
Similar procedures for assessment are used although many specific tools are not developed or validated on
juveniles. As a result,the number of appropriate tests for juveniles is reduced All juveniles aged 15 years and
older receive:
Juvenile MMPI-II Wilson Sex Fantasy Questionnaire
Juvenile Multisex Inventory IGTS Forensic Interview
Juvenile Culpability Scale IGTS Offender History Questionnaire
High School Questionnaire Preference(HSPQ)
If necessary,the PPG and polygraph can be given.For clients under the age of 15,the number of sex offense
specific tools is reduced further. We utilize the clinical interview, the Juvenile Culpability Scale, and the
School Questionnaire Preference. For clients who are developmentally disabled,the clinical interview is used
as well as the Juvenile Culpability Scale.
If an adult offender is accepted into the program, polygraphs are required. The polygraphers utilizd m our
program are Lawson Hagler of Loss Accountability Services and Gwen Knipscheer of Alverson and Associates,
both of whom are approved by the State Sex Offender Board.
PPG is utilized to measure the sexual interests of a sex offender. PPG is a tool utilized to accurately assess
sexual arousal patterns. PPG is not to be done on juveniles below the age of 15. IGTS has the only approved
PPG lab in Weld County.In addition,PPG is utilized to verify whether behavioral techniques taught to each
client are,in fact,effective.
All evaluations are supervised by approved personnel at KITS. These individuals have met the rigorous
requirements of the State of Colorado for sex offender providers. Currently KITS and N.RB.H. are the only
programs in Weld County to have approved staff available to treat adult sex offenders.
IV. MEASURABLE OUTCOMES
Each family member admitted to outpatient services of N.R.B.H. will be evaluated at admission and at
discharge from SAT services using the Colorado Client Assessment Record (CCAR) developed by the
Colorado Office of Mental Health Services. This form provides a wide range of inquiry into an individual's
levels of functioning. The Family Preservation Program Admission and Temimation Evaluation Forms are also
to be used as evaluation tools. These look specifically at the effects of the ITT program. Copies of these forms
are attached at the end of this proposal.
Through the SAT project, N.RB.H. will work to enable families with children at risk of out-of-home
placement or who already have children placed out of their homes to care for those children in a healthful,
safe,and nurturing manner in the home environment. Specific goals and objectives are to:
Goal A. Rapidly improve and stabilize family functioning to enable the family to care for the children
in the home setting.
Objective. Provide family preservation services starting within three days of referral to client
families to either prevent out-of-home placements of children and adolescents in
foster and group homes,residential child care facilities,juvenile detention facilities,
and in psychiatric hospitals(family preservation services)or return youths from such
facilities to their family homes within three weeks of referral(family reunification
set)
Goal B. improve the overall functioning of the client families via improved family conflict
management,improved parental competency,improved household management competency, and an
improved ability to gain access to and use appropriate resources in the community to enable the
families to appropriately care for the children in their own homes on a long term basis.
Objective a. Eighty-five percent of the families that successfully complete either family
preservation or reunification services through the SAT project will measure
significantly lower on the risk assessment scales at time of termination of services.
Objective b. At discharge,six,and 12 months after the successful termination of services, 90%of
the families will remain intact.
Objective c. Seventy-five percent of children currently in long term placement who are provided
reunification services will return to their own homes and not reenter out-of-home
placement within 12 months of completion of services.
Objective d. Fewer than 10%of the discharged children will enter another family preservation
service unless such transfer is deemed to be in the best interest of the children.
Objective e. Fewer than 10% of the children saved will be in a more costly placement at
discharge and fewer than 15%will be in such a placement six months after discharge.
Objective f. Eighty percent of the families receiving either family preservation or reunification
services will not have a substantiated incident of abuse or neglect filed against them
during the course of treatment nor within 12 months of successful completion of
services.
Goal C. To significantly reduce instances of recidivism and re-victimization in the client families.
Objective a. To reduce the rate of recidivism of sexual assault to zero in families successfully
completing treatment in which the perpetrator of such assaults is a child, adolescent,
or adult family member.
Objective b. To reduce the rate of re-victimization of any abused member of the client family by
anyone in or outside the family to zero in families successfully completing SAT
services.
Objective c. To prevent the transition of a child or adolescent who has been sexually abused into
a perpetrator of sexual assault for all such individuals successfully completing SAT
services.
V. SERVICE OBJECTIVES
In working with families to achieve the goal of improving their abilities to manage family conflict in a safe,
constructive manner,the SAT worker strives to accomplish the objective of resolving conflicts between the
parents,the children,and the parents and children so that no mahtreatmmt of the children occurs,no domestic
violence occurs,no children run away from home,and no children commit status or legal offenses. Success
in meeting this goal will be measured by family,caseworker,and therapist reports that the objectives were met.
The family will also be asked to report on their subjective improvements in this area.
To meet the goal of improving overall parental competency,the objective of increasing the parents'abilities
to develop and maintain sound,caring,effective relationships characterized by clear, appropriate physical and
emotional boundaries with each other and with their children is established. Furthermore,power discrepancies
within the family are corrected with the empowerment of the non-abusing parent(s)and the victims of the
sexual abuse. An additional objective is to enhance the abilities of the parents to provide as well as possible
for their family's care,nutrition,hygiene,discipline,protection,education,and supervision. Again,the parents
and children will be polled as to their subjective opinions about the improvements they have made as will the
therapist and caseworker.
Additionally,the SAT services focus on the goal of improving personal and individual competencies within
the family. Objectives are established to develop and maintain functional levels of self esteem, victim
awareness, awareness and management of one's personal history of victimization, sexual education, peer
relationship enhancements, appropriate emotional and physical boundaries, the use of assertion in lieu of
aggression,and in assumption of responsibility for one's own behaviors.
The fourth service goal of the project is to improve household management competency. The objective is to
enhance the capacity of the parents to provide a safe household environment for the children through
competently managing the home to include cleaning, repairing, and maintaining the home, budgeting, and
purchasing. Families who do not have a working financial budget will develop and adhere to one with the
assistance of the therapist The family,therapist,and caseworker documents the improvements made in this
area.
The fifth service goal of SAT is to improve the family's ability, individually and collectively,to find and use
appropriate resources. Treatment and case management services assists the family to learn more effective
means of obtaining needed help from other sources in the community as well as from local, state, and federal
governments. The families will report, and their caseworker and therapist will confirm gains in this goal and
objective.
VL WORKLOAD STANDARDS
A worker in the Family Preservation Team(FPT)of N.RB.H.has a caseload of not more than the equivalent
of eight SAT families at any given time. The equivalent at a mini®u,of two full time workers will provide
SAT services at any given time. Each will provide an average minimum of three hours of direct, outpatient
finally preservation or reunification services per family per week. The Rai=of two hours suggested in The
Colorado Department of Social Services Staff Manual Volume 7 is too bare a minimum,not sufficient to the
task set out for SAT workers at N.R.B.H.. The three hours do not include the time required to be spent
receiving clinical supervision, participating in in-service training,or in traveling to reach the client families
served. Also not included in the three hours are the case management hours required to assist the family
achieve its goals and objectives that are done in the family members'absence.
Direct supervision of the SAT project occurs within the context of the larger FPT. This team,as designed and
as presently proposed in this document and others, comprises seven individuals:the full time equivalent of six
mental health workers and one supervisor. The supervisor,Pat Orleans,LCSW, who is also the director of
the Children and Family Services Program(CFSP),reports directly to the Executive Director of N.ltB.H., Dale
F. Peterson, MSW MBA The supervisor provides clinical oversight and administration directly to the
project as well as clinical supervision to newly employed members of the team for at least the first six months
of their employment. After the initial sir months, an employee may be permitted to choose a clinical
supervisor from among the other qualified staff of N.RB.IL Ms. Orleans is clinically supervised by Larry
Pottorg LCSW. Also in the clinical and administrative chains of command,and available for consultation
with staff are N.R.B.H.'s Medical Director,Ted Sills,MD. A board certified child psychiatrist Russ Johnson,
MD and two board certified general psychiatrists, Jim Medelman, MD and Enrique Alvarez, MD, are also
available to consult with the FPT staff and to psychiatrically evaluate family members in need of such services.
The present treatment team members fully assigned to the FPT are Josephine I nrero,MA LPC, Rich Hedhmd,
MA LPC, Jami Moe-Hartman, MA, and Greg Creed, BA(to receive MA in May, 1999). Their efforts are
augmented by other staff;including Meg Baker,LCSW,Greg Bjodk,MA LPC,Lin Moersen,MSW,Ave Maria
Williams,MSW,and Leonor Wills,MA LPC, from N.R.B.H.when necessary to cany out the service plan of
a client family. Additionally, staff members of Individual, Group, and Family Treatment including Mery
Davies,MA CACIII,Deana Helsel,MA, and Kim Ruybal, MA,are an integral part of the treatment staff for
some of the referred families. Several of these therapists are state approved providers of offense specific sexual
offender treatment.
VIL STAFF QUALIFICATIONS
All staff of N.R.B.H.'s Family Preservation Team(FF1)exceed,and those hired in the future will meet,as a
mini®,the qualifications=cottony to he a Caseworker III within the state social services system. That is,
each is required to have at least a bachelor's degree in one of the human behavioral science fields and at least
the equivalent of two years of professional mental health or social services experience performed after
completion of the degree. All=tent members of the team have masters or higher degrees in the human
services area from accredited universities and at least two years experience working with children and families.
Due to the use of the team approach,the members of the team,while specializing in the provision of family
preservation services, carry a diverse caseload in that each may provide a combination of the four different
types of family preservation services offered by N.R.B.H.. This aspect of the FIT will be staffed according to
demand for services from W.C.D.S.S.. The equivalent of two full time employees, at a minimum, will be
continually available to provide SAT services at any given time. Additional staff will be hired to handle
whatever number of referrals may be made.Each member of the FPT will be knowledgeable in family and
individual dynamics and in the treatment of sexual abuse as demonstrated by specialized training,workshops,
and experience in the area. Each FPT member working with a family within the SAT will receive a monthly
minimum of four hours of clinical supervision from an N.R.B.H. staff member with advanced skills in sexual
abuse treatment or family therapy. This supervision will address such things as diagnostics,treatment planning,
use of the self in the treatment relationship, strategies of intervention,dealing with resistance,and obstacles
to the treatment process. All members of the team and involved clinical supervisors will complete not less than
12 hours annually of continuing education in the area of sexual abuse treatment and prevention. Those clinical
staff providing offense specific sexual offender treatment will meet all state requirements for such workers.
Those staff providing the highly specialized assessments required in the treatment of sexual offenders such as
penile ple hysmog apha and polygraphs will meet state standards as examiners in these areas. Psychiatrists and
psychologists whose services are used will be licensed practitioners in Colorado.
•
RFP-FYC-99007 Attached A
VIII. COMPUTATION OF DIRECT SERVICE RATE
This form is to be used to provide detailed explanation of the hourly rate your
organization will charge the Core Services Program for the services offered in
this Request for Proposal. This rate may only be used to bill the Weld County
Department of Social Services for direct, face-to-face services provided to
clients referred for these services by the Department. Requests for payment based
on units of service such as telephone calls, no shows, travel time, mileage
reimbursement, preparation, documentation, and other costs not involving direct
face-to-face services will not be honored.. Likewise, billings must be for hours
of direct service to the client, regardless of the number of staff involved in
providing those services. Therefore, it is imperative that this rate be
sufficient to cover all costs associated with this client, regardless of the
number of staff involved in providing these services.
(Explanations for these Lines are Provided on the Following Page)
Total Hours of Direct Service per Client 135.19 Hours [A]
Total Clients to be Served 16 Clients [B]
Total Hours of Direct Service for Year 2,163 Hours [C]
(Line [A] Multiplied by Line [B]
Cost per Hour of Direct Services $ 35.70 Per Hour [D]
Total Direct Service Costs $ 77,219.10 [E]
(Line [C] Multiplied by Line [D] )
Administration Costs Allocable to Program $ 29,935.92 [F]
Overhead Costs Allocable to Program $ 40,512.99 [G]
Total Cost, Direct and Allocated, of Program$ 147,668.01 [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] ) $ 147,668.01 [J]
Total Hours of Direct Service for Year 2,163 [K]
(Must Equal Line [C] ) ----
Rate per Hour of Direct, Face-to-Face Service
to be Charged to Weld County Department of
Social Services $ 68.27 IL]
Day Treatment Programs Only:
Direct Service House Per Client Per Month (M]
Monthly Direct Service Rate $ (N]
Page 34 of 35
VIIL RATE COMPUTATION:BUDGET DESCRIPTION
Personnel costs are predominant in this budget. The above figures represent the equivalent of two full-time
clinical staff members of North Range Behavioral Health(NRBH)waiting within the Sexual Abuse Treatment
services and the necessity of additional services called for by service plans and the requirements set forth in
the proposal,including clinical,case management,support,and supervisory sat. Direct sat personnel
costs equal$35.70 pa direct service how,or 52%of the total of$68.27. Supervisory costs are$9.99,or 15%
of the total direct time cost. The clerical support services costs are$3.85, or 6%of the total. The agency
overhead of$18.73 amounts to 27%of the total cost per hour. Psychiatric and psychological services are
available at an hourly rate of$92.56 for those clients needing them and will be billed separately from other
clinical costs. Plethysmographic evaluations are available at a cost of$210.00 including a written report and
$150.00 without such a report. Polygraphic evaluations we available at a cost of$180.00 including a report.
Charges far psychiatric,psychological,pledirmographic,and polygraphic services will be made separate from
the rate set forth above.
All MC funds will be accounted for separately within the overall budget of North Range Behavioral Health.
Each project is regarded as a distinct cost center. North Range Behavioral Health is independently audited
annually,including its use of PAC funds.
IX. PROGRAM CAPACITY BY MONTH
The SAT is designed to function with a minimum staff contingent of 2.00FFE, saving up to 16 children and
their families at any given time throughout the upcoming fiscal year. N.R.B.H.will be pleased to accept as
many additional families as are determined to need this level and type of care. We will develop sufficient
staffing patterns to accommodate any and all families needing the SAT service.
ACORD ERTinsA1EOF�IR:;#SU NCE 0DATEmwmmli
3/0
PRDDIx ER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Flood & Peterson Ins. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. O. BOX 578 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
4687 W. 18th Street COMPANIES AFFORDING COVERAGE
Greeley, CO 80632
COMPANY
ACNA Insurance
INSURED -- —
North Range Behavioral Health COMPANY
1306 11th Avenue -- —
PANY
Greeley, CO 80631 0061
-COMPANY -- --
D
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDINON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Li�R TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
DATE(MM/DDNY) DATE(MWDDNY)
A Dsi ns- NUVIm S182327225 01/01/99 01/01/00 GENERAL AGGREGATE e , 000, 000
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG 13, 000, 000
CLAIMS MADE X OCCUR PERSONALS ADV INJURY S1, 000, 000
OWNER'S S CONTRACTOR'S PROT EACH OCCURRENCE e, 000, 000
FIRE DAMAGE:(Arty one fire) s5 0, 0 0 0
MED EXP(Any one Penton) $5, 0 0 0
A AUTOMOBILE LIABILITY S182327225 01/01/99 01/01/00 COMBINED SINGLE LIMIT S1, 000, 000
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY S
X SCHEDULED AUTOS (Per Person)
X HIRED AUTOS
BODILY INJURY S
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE S
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY
EACH ACCIDENT S
-_ AGGREGATE fA EXCESS LIABILITY S182327225 01/01/99 01/01/00 EACH OCCURRENCE f2, 000L000
X UMBRELLA FORM AGGREGATE $2, Q Q 0 iQ Q O
OTHER THAN UMBRELLA FORM f
WORKERS COMPENSATION AND STATUTORY LIMITS
EMPLOYERS'LIABILITY EACH ACCIDENT f
THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT S
PARTHERS/FXECUTNE - - --— -
OFFICERS ARE , EXCL DISEASE-EACH EMPLOYEE S
A OTHER Prof . Liab.IS182327225 01/01/99 01/01/00 $1, 000 , 000 ea. pers .
- Claims Made $3 , 000 , 000 total limi
DESCRIPTION OF OPERATIONS/LOCATONSNEHICLESISPECIAL ITEMS
Retro date 7/1/86
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Weld County Placement EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Alternatives Committee '()_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
c/o Weld County, Department of BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Social Security OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
800 8th Avenue AUTHORIZEDREPRESENTATTVE
Greeley, CO 80631 Rood* Pete 1Sar. rrh.SCrACZne, , Ir3C-
ACORD264(8(B3)1 of1 4S100da3/MI000st PPM 0 ACORD CORPORATION 1093
• M
l COLORADO CLIENT ASSESSMENT RECORD 1 I
NAME: ■III GAF SCORE
ETHNIC/RACE 74
AGENCY1a I I [PROGRAM44 (1)American Indian/Alaskan Native
I I I I I I I I I ICUENT ID F14 (2)Asian/Pacific Islander
(3)Black
I I I I I I I I I (REFERRING AGY, (4)Hispanic
CUEWI ID 1us (5)White(Non-Hispanic)
(6)Multi-Racial
I I I I I I I I I MEDICAID ID 24a2 HISPANIC ORIGIN 7s
MI
1 ADMISSION DATE a340 (1)Not of Hispanic Origin
MONTH DAY YEAR (2)
(3)Puerto Rican
I ACTION TYPE (Manual Input Only) 41-42 (4)Cuban
_ (5)Other Hispanic
01=Admission 11=Correction to Admission MARITAL STATUS 7c
02=Activate 12=Conedlon to Activation
03=Update 13=Correctlon to Update (1)Never Married (4)Widowed
04=Inactivate 14=Carredbn to Inactivation (2)Married (5)Divorced
05=Discharge 15=Corndion to Discharge _ (3)Married Separated(Legal or Marital Discord)
06=Evaluatlon Only PLACE OF RESIDENCE n I
I MEDS ONLY CLIENT 4.1 (1)Correctional Facility(Jail
Inpatient
(1)Yes (2)No (3)(J) n9 N Home
4)Residential Facility-Mental Health
ADMISSION STATUS at (5)Residential Facility-Non-Mental Health
(1)New Admission (6)Boarding Home
(2)Readmission From This Fiscal Year (7)Homeless-In Shelter
(3)Readmission From Prior Fiscal Year (8)Homeless-On the Street
PERMANENT HANDICAP/IMPAIRMENT 4141 (9)Other Independent Living Arrangement
(Code ALI,5 Boxes Using 1 Yes 2 No) CURRENT LIVING ARRANGEMENT 7s
(1)Mental Retardation (1)Lives With Both Parents
(2)Deafness or Severe Heating Loss (2)Lives With One Parent
(3)Blindness or Severe Visual Impairment (3)Lives With Spouse and or Other Relative(s)
(4)Speech 4 Lives Alone
(5)Non-Ambulatory or Assisted Ambulation _ (5)Lives With Unrelated Person(s)
CURRENT EMPLOYMENT STATUS is
I LEGAL STATUS 50 (1)Employed-Full Time
(1)Voluntary (2)Employed-Part Time
(2)Court-Deeded Voluntary (3)Homemaker-Not Otherwise Employed
(3)Forensic:Involuntary (4)Sheltered Employment
(4)72-Hour Evaluation and Tieakr ICI it(MH-HOLD) (5)Not in Labor Force
(5)Short-Term Certified (6)Unemployed For Less Than 3 Months
(6)Long-Term Certified m Unemployed For 3 Months or More
(7)Voluntary Hospitalization of Minors (8)Armed Forces(Active Military Duty)
(8)Chlldrens'Code C.R.S.19-1-101
(9)Emergllnvol.Alcoholism/Dug Commitment ANNUAL FAMILY HOUSEHOLD INCOME seat
iMain 1
IT I I
REFERRAL SOURCE 6142 _ ' I I I
PRIMARYDIACNOSIS SECONDARY DIAGNOSIS e2.67 NUMBER OF PERSONS SUPPORTED BY' a
- (d applicable) THIS INCOME(Include Client)
I I I .1 1 I F I I I 1 I (1)1 (dent«,M (6)6
PRESENTING PROBLEM HAS EXISTED ss (2)(3)23 ()7
(1)1 Year or Longer (2)Less Than 1 Year (4)4 (9)9 or More
PREVIOUS MENTAL HEALTH SERVICES sin _ (5)5
(Code ALL Four Boas Using 1 Yes 2 No) HIGHEST EDUCATION LEVEL-IN YEARS seer
Inpatient Care (Less Than First Grade Code as 00)
Other 24-Hour Care DUE TO MENTAL HEALTH REASONS, a
Partial Care CLIENT IS CURRENTLY RECEIVING:
Outpatient Care (1)SSI (3)Both
I I COUNTY OF RESIDENCE a44 _ (2)SSDI (4)Neither
DATE OF BIRTH a.n _FIRST 3 LETTERS OF CLIENTS LAST NAMEaa1 I I I
OW 04SMaligitegal Vaal ZIP CODE nos 17-100
MONTH DAY YEAR _ [ I I IL1 'f I I
SEX 7i Triage Denver Health&Medical Center Only 10i
(1)Male (2)Female
• M
COLORADO CLIENT ASSESSMENT RECORD 2
I
Client I.D. Name_ Admit Date
HISTORY 102-10e Check ALL that Apply CURRENT PSEV Check ALL Problems that Apply
Vict:_ Sepal Abuse Hist:Suicide Attempt _Hill:Unstable Empleym [] AGGRESSIVENESS 1e+-187
Vict:Physical Abuse Hut:Family Silent-II
Viet:Neglect Hist:Family Sub-Abuse —Acting Out —Defiant —Threatening
Aggressive Hostile Intimidating
SPECIAL PROBLEMSASSUES +off-its Check ALL that Apply ^� n — —
sociAL +9e-203
Learning Disability CNS Disorder language Issues
— _ Disrespect Disregards Rules Uses/Cons Others
Loss/Grief Wetting/Soiling _Cultural/Belief Issues —_ —
Eating Disorder _Fire Set/Destroy Property _ Disobedient _Dishonest
PROBLEM SEVERITY fl] LEGAL 204-210
_ Legal Problems _Probations/Parole Offenses:Property
RATE the CURRENT PSEV(PROBLEM SEVERITYI __Changes Pending —Offenses:Substances _Offenses:Persons
for each area in the boxes provided,using the following scale: �1 VIOLENCE/DANGER TO OTHERS xttan
None Slight Moderate Severe Extreme
t - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 Violent Homicidal Ideation
_ Assaultive Homicidal Threat/Attempt
CURRENT P-SEV Check ALL Problems that Apply __Phys/Sexual Abuser Danger to Others MatiatiN
EMOTIONAL WITHDRAWAL to-+n ni FAMILY ISSUES 21e-n5
Underactive _Passive _Doesn't Verbalize Feelings
DistantSubduedBlunted Affect No Family/No Contact _Family Legal _Domestic Violence
- Out of Home Placement Parenting Unstable Horne/Fam
DEPRESSION 134130 --SeparattaJCustody — —
— WITH n
Depressed _Lonely Hopeless [] FAMILY PROBLEMS 6-x3+
Worthless Sad Dejected
__Parent _Partner _Relative
ANXIETY 131-139 _ Sibling _Child
Anxious _Nervous _Panic I—] INTERPERSONAL PROBLEMS 232-236
Tense Flashbacks Phobic
-Fearful Nightmares/Terrors __w/Friend _Establishing Relationships
Social Skills Maintaining Relationships
HYPER AFFECT uo-tte —'
_Overactive _Pressured Speech _Elevated Mood p] ROLE PERFORMANCE(Work/Schooll 237-243
Mood Swings Accelerated Speech Mania
Absenteeism Performance Behavior
ATTENTION PROBLEMS u7-t 53 __Suspenekn/ ro Pbation _Termination _Limited Employability
_Agitated Distractible Attention Span C] SUBSTANCE ABUSE 2s4x49
Restless Impulsive Concentration
— Problem w Alcohol _Dependent/Addicted In Recovery
SUICIDE I DANGER TO SELF - +ss-+so ____Problem w Drugs _Interferes with Responsibilities
Suicide Ideation _Self-Injury/Mutilation 1-1 MEDICAL/PHYSICAL no-ne
Suicide Plan Recldess Self-Endangerment
Suicide Attempt —Danger to Sett Acute Illness —Medical Care Needed —Phy.:,-al Handicap
(Ct?.5.`i7':it?{£�:_:s..; - Chronic Illness —InjuryByAMrcdAssaul —Permanent Disability
THOUGHT PROCESSES +et-tss
1---] SECURITY/MANAGEMENT ISSUES 257-265
Bizarre Suspicious Repeated Thought
Delusions Paranoid Obsessive Seclusion/TimeOt _Walkaway/Escape —Behavior Managemt
Hallucinations —
__— Clew Supervision Security _
—
Suicide Watch
— Medication Compliance Inadequate Adult Supervision
COGNITIVE PROBLEMS 169-173 --
_Confused _Loose Associations _Lacks Self Awareness OVERALL DEGREE OF PROBLEM SEVERITY 266
_Disoriented _Disorganized _Impaired Judgement Check ONE Response
SELF-CARE/BASIC NEEDS rnv3 None Slight Moderate Severe Extreme
Hygiene DoesniManage Money Doesn't Provide Food I 2 3 4 5 6 7 8 9
_
Self Care Problems Doesn't Use Resources Doesn't Provide Housing
_Gravely Disabled ttlRSa"2''10j.. UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL PROBLEM SEVERITY 267
RESISTIVENESS +16-190 Check ONE Response
Resistive Evasive Wary Much Much
—Uncboperative —Guarded —Deni Better
Denies ProblBetterBetter No Change Worse Worse
-2 2 - 3 4 - 5 - 6 7 8 9
I COLORADO CLIENT ASSESSMENT RECORD 3
I
Client I.D. Name Admit Date
STRENGTHS/RESOURCES r LEVEL-OF-FUNCTIONING (LOF)
Check ALL CURRENT STRENGTHS I RESOURCES IndMWIW Cheek ONE Re
sponse esponse for Each LOF Area
ECONOMIC RESOURCES 25M' 4 SOCIETAL I ROLE FUNCTIONING b4
Med_ lakN.kdkare Employment _Transportation Very High Moder High Average Moder Low Very Low
_Other Medical Housing l l _ Function Function Function Function Function
_Other Public Assist _Flmncial _
EDUCATION I SKILL RESOURCES 27s279 t 2 3 4 5 6 i 9 9
am
Language Sides Skills Intelligence_ _ INTERPERSONAL FUNCTIONING
Education Job Skills Very High Moder High Average Moder Low Very Low
— — Function Function Function Function Function
PERSON RESOURCES 250-287
_Parent(s) _Partner _Professional Caregiver 1 2 3 4 5 6 7 e 9
Sibling(:) Chiid(ren) _Other Supportive Relationship DAILY LIVING/PERSONAL CARE FUNCTIONING 304
_R- elative(s) _Friend(=) Very High Moder High Average Moder Low Very Low
PERSONAL STRENGTHS 2e8a01 Function Function Function Function Function
Likeableness _Emotional Stability _Adaptability 1 2 3 4 5 6 7 8 9
_Appearance _Health Though YSICAL Clarity PH FUNCTIONING
Confidence _Hopefulness _Resourcefulness b7
Judgement Responsibility Tolerance Very High Moder High= Average Moder Low Very Low
—Empathy —Insight Function Function Function Function Function
1 2 3 4 5 6 7 8 9
COGNITIVE/INTELLECTUAL FUNCTIONING be
Very High Moder High Average Moder Low Very Low
Function Function Function Function Function
1 2 3 4 5 6 7 8 9
CURRENT OVERALL STRENGTHS/RESOURCES 302 OVERALL LEVEL OF FUNCTIONING Check ONE Response 30S
Check ONE Response
Very High Moder High Average Moder Low Very Low
Very High High Moderate Some Very Low Function Function Function Function Function
1 2 3 4 5 6 7 8 9 . 1 9 3 4 5 6 7 8 9
UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL STRENGTHS/RESOURCES 303 CHANGE IN LEVEL OF FUNCTIONING Check ONE Response 310
Check ONE Response Much Much
Much Much Better Better No Change Worse Worse
Better Better No Change Worse Worse _ _
1 2 3 4 5 6 7 8 9
1 2 3 4 5 8 7 8 9
I I I I I I STAFF ID a11a19 STAFF SIGNATURE
Ei DISCIPLINE' 1=none 2=mh worker 3=nursing 4-social work 5=psychology 6=psychiatry 7=other 123
DEGREE 1=note 2=assodate 3=bachelors 4-masters 5=PhD/PsyD/EdD 6=MD 7=other 321
COMPLETE THIS BOX ONLY FOR COMPLETE THIS BOX ONLY AT DISCHARGE
UPDATE,ACTIVATE AND INACTIVATE STATUS C ElE]
DATE FORM COMPLETED
MONTH DAY YEAR 330-337
C En LAST CONTACT DATE
MONTH DAY YEAR 338445
__ EFFECTIVE DATE322an C �� DISCHARGE DATE
MONTH DAY YEAR MONTH YEAR 344-353
1-1 TYPE OF TERMINATION. 354
SPECIAL STUDIES 1'DischargedtTransferred 5-From Inactive
2-TX Completed/No Referral Walied/Client Died
35Ta64 3-TX Completed/Follow-up 7-Patent/Client Terminated
4-Evaluation Only
36?a7s C I J TERMINATION REFERRAL' 353a36
NOTE: Use 61 'Self if no Referral
FAMILY PRESERVATION PROGRAM ADMISSION EVALUATION FORM (7/97)
Client Name _ Client Idii
Diagnosis: Primary Secondary
Date of Birth School Grade City
Admit Date Center
Medicaid _ Yes _ No (Check One) Sex _ Ethnicity
Who had custody of youth at time of referral to FPP
Where was youth residing at time of admission to FPP (Be specific) _
Date of initial referral for FPP services
Date of first contact by FPP therapist
FPP Therapist
Previous mental health services (explain)
Special Behaviors or Circumstances/Reasons for referral
PAST PRESENT
Yes No Yes No
Suicidal
Violence toward others — — — —
Runaway Behavior — — — —
Social Isolation — — — —
Legal Charges — — — —
Domestic Violence
On Probation
Victim Physical Abuse — — —
Victim Sexual Abuse
Alcohol Use
Use of InhalantsOther Drug Use — — _ —
Learning Disabilities — —
Special Education _ — —
Bed Wetting
Encorpresis — _ —
Others (specify
GAF SCORE AT ADMISSION TO FPP
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNCTIONING SCORES AT ADMISSION TO FAMILY PRESERVATION PROGRAM
(RATE ALL SIX AREAS)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
SOCIETAL FUNCTIONING
INTERPERSONAL FUNCTIONING
DAILY LIVING PERSONAL CARE
PHYSICAL FUNCTIONING
COGNITIVE INTELLECTUAL
OVERALL LEVEL OF FUNCTIONING
FAMILY PRESERVATION PROGRAM TERMINATION EVALUATION FORM (7/97)
Client Nave Client IS
Discharge date fran FPP _
List all different types of FPP services used
Discharge Diagnoses: Primary Secondary
Who has custody of child at time of termination fran FPP?
Where was child living immediately after termination fran FPP?
Who will follow youth after discharge?
Special Behaviors or Ciranstances
PRESENT
Yes No
Suicidal
Violence toward others
Runaway Behavior _
Social Isolation
Legal Charges _
On Probation
Victim Physical Abuse
Victim Sexual Abuse _
Alcohol Use
Use of Inhalants
Other drug use
Learning Disabilities
Special Education _Bed Wetting
Encorpresis _
Domestic Violence
Others (specify)
OAF SCORE AT DISCHARGE
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNCTIONING SCORES AT DISCHARGE FROM FAMILY PRESERVATION PROGRAM
(RATE ALL SIX AREAS)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
SOCIETAL FUNCTIONING
INTERPERSONAL FUNCTIONING
DAILY LIVING PERSONAL CARE
PHYSICAL FUNCTIONING
COGNITIVE INTELLECTUAL
OVERALL LEVEL OF FUNCTIONING
oaf •K
North Range
Behavioral Health
May 19, 1999
Judy A. Griego, Director
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
Re: RFP Recommendations and Conditions
Dear Ms. Griego:
The purpose of this letter is to respond to the recommendations and conditions specified in
your letter of May 14, 1999.
Intensive Family Therapy (RFP 99008)
1. Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (b)
Payment will be denied to IFT providers for any charges submitted foe therapy 45 minutes
or less unless cleared by explanation and approved by the program area supervisor.
NRBH Response: (a) IFT providers will receive further training and closer supervision, in
order to insure that quarterly reports are made in a timely manner. (b) This condition is
understood and it will be communicated to the appropriate IFT and billing personnel.
Option B (RFP 99010)
2. Recommendation: The program should be goal. oriented. This program does receive
more than eight referrals a year.
NRBH Response: Close supervision will take place in order to insure that the program
remains oriented toward fulfilling the goals expressed in the proposal. The Option B
Program will be prepared to accept significantly more than eight referrals, as needed.
Option B (RFP 99010) continued
2. Condition: Submit timely quarterly reports to caseworkers and offer more flexibility
with time frames for clients.
NRBH Response: Option B providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner. Additionally, closer
supervision and the further addition of potential providers will allow more time frame
flexibility.
Sex Abuse Treament(RFP 99007)
3. Recommendation: Submit timely quarterly reports to caseworkers.
NRBH Response: Treatment providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner.
Day Treatment (RFP 99006)
4. Recommendation: The caseworker shall be involved in the assessment process.
NRBH Response: The is little doubt that the involvement of the caseworker is a necessity
in the assessment process. Closer supervision will occur to insure that greater effects are
made to contact and communicate with caseworkers during tha assessment process.
If you have any further concerns or questions please let us know and we will address them
as quickly and effectively as possible.
Sincerely,
Cha es A. Howard, h.D.
Director of Children and Family Services
Dale F. Peterson, M.S.W., M H A, Director
North Range Behavioral Health
C
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
GREELEY, CO 80632
Administration and Public Assistance(970)352-1551
C. Child ervpoA(970)352-69331
Protective and Youth Services (970) 352-1923
COLORADO May 14, 1999
Mr. Dale Peterson, Director
North Range Behavioral Health, Inc.
1306 11 Avenue
Greeley, CO 80361
Dear Mr. Peterson:
Re: RFP 99008 (IFT) Intensive Family Therapy
RFP 99010 Option B -
RFP 99007 Sex Abuse Treatment
RFP 99006 Day Treatment
Dear Mr. Peterson:
The purpose of this letter is to outline the results of the RFP Bid process for PY1999-2000 and to
request written information or confirmation from you by May 20, 1999.
A. Results of the RFP Bid Process for PY1999-2000
On April 7, 1999, the Families, Youth and Children (FYC) Commission approved the
RFP(s) listed above for inclusion on our vendor list. The FYC Commission attached the
following recommendations and/or conditions regarding your RFP bid(s).
1. RFP 99008, Intensive Family Therapy:
Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (h)
Payment will be denied to Intensive Family Therapy providers for any charges
submitted for therapy 45 minutes or less unless cleared by explanation and
approved by the program area supervisor.
2. RFP 99010, Option B:
Recommendation: The program should be goal oriented. This program does
receive more than eight referrals per program year.
Condition: Submit timely quarterly reports to caseworkers and offer more
flexibility with time frames for clients.
Page 2
North Range Behavioral Health/May 14, 1999
3. RFP 99007, Sex Abuse Treatment:
Recommendation: Submit timely quarterly reports to caseworkers.
4. RFP 99006, Day Treatment:
Recommendation: The caseworker shall be involved in the assessment process.
B. Required Response by RFP Bidders Concerning FYC Commission
Recommendations and Conditions.
The Weld County Department of Social Services is requesting your written response to
the FYC Commission's recommendations and conditions. Please respond in writing to
David Aldridge, Weld County Department of Social Services, P.O. Box A, Greeley, CO,
80632, by May 20, 1999, close of business, as follows:
1. FYC Commission Recommendations:
You are requested to review the FYC Commission recommendations and to:
a. accept the recommendation(s) as written by the FYC Commission; or
b. request alternatives to the FYC Commission's recommendation(s); or
c. not accept the recommendation(s) of the FYC Commission.
Please provide in writing how you will incorporate the recommendation(s) into your
bid. If you do not accept the recommendation, please provide written reasons why.
All approved recommendations under the NOFAA will be monitored and evaluated
by the FYC Commission.
2. FYC Commission Conditions:
All conditions will be incorporated as part of your RFP Bid and Notification of
Financial Assistance Award (NOFAA). If you do not accept the condition(s), you
will not be authorized as a vendor unless your mitigating circumstances arc accepted
by the FYC Commission and the Weld County Department of Social Services. If you
do not accept the condition, you must provide in writing reasons why. A meeting will
be arranged to discuss your response. Your response to the above conditions will be
incorporated in the REP Bid and Notification of Financial Assistance Award.
Page 3
North Range Behavioral Health/May 14, 1999
If you wish to arrange a meeting to discuss the above conditions and/or recommendations, please
do so through Elaine Furister, 352.1551, extension 6295, and one will be arranged prior to May
20, 1999.
Sincerely, a
J A. 5nego, D recto
d County Department of Social Services
cc: Mike Hoover, Chair, FYC Commission
David Aldridge, Social Service Manager II
JG:ef
Weld County Department of Social Services
Notification of Financial Assistance Award
for Families,Youth and Children Commission (Core)Funds
Type of Action Contract Award No.
X Initial Award FY99-PAC-2001
Revision (RFP-FYC-99010)
Contract Award Period Name and Address of Contractor
Beginning 06/01/1999 and North Range Behavioral Health
Ending 05/31/2000 Option B -Mobile Mental Health Team
1306 11th Avenue
Greeley, CO 80631
Computation of Awards Description
Unit of Service The issuance of the Notification of Financial Assistance
Service to at least eight families needing Award is based upon your Request for Proposal (RFP).
moderately high level of care. The service offers 'The RFP specifies the scope of services and conditions
a range, on average, of three to five hours of of award. Except where it is in conflict with this
weekly in-home mental health services for up to NOFAA in which case the NOFAA governs, the RFP
nine months to each family in crisis. upon which this award is based is an integral part of the
action.
Cost Per Unit of Service Special conditions
Hourly Rate Per $ 68.27 1) Reimbursement for the Unit of Services will be based
Unit of Service Based on Approved Plan on an hourly rate per child or per family.
2) The hourly rate will be paid for only direct face to face
contact with the child and/or family, as evidenced by
client-signed verification form, and as specified in the
unit of cost computation.
3) Unit of service costs cannot exceed the hourly, and
yearly cost per child and/or family.
Enl r�r : 4) Rates will only be remitted on cases open with, and
Signed RFP:Exhibit A referrals made by the Weld County Department of
Supplemental Narrative to RFP: Exhibit B Social Services.
✓Recommendation(s) 5) Requests for payment must be an original and submitted
to the Weld County Department of Social Services by
✓Condit ons of Approval
the end of the 25th calendar day following the end of the
month of service. The provider must submit requests
for payment on forms approved by Weld County
Department of Social Services.
Approvals: Program Official:
By /r. s By 1_
Dale K. Hall, Chair Judy A. riego, irector
Board of Weld County Commissioners Weld C unty D partment of Social Services
Date: c /,; 9 9 Date:_ � _—__
q%!02 7 (4')
INVITATION TO BID
DATE: February 26, 1999 BID NO: RFP-FYC-99010
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-99010) for: Family Preservation Program--Home Based Intensive
Family Intervention Program Family Issues Cash Fund or
Family Preservation Program Funds
Deadline: March 23, 1999, Tuesday, 10:00 a.m.
The Families, Youth and Children Commission, an advisory commission to the Weld County Department of
Social Services, announces that competing applications will be accepted for approved vendors pursuant to the
- Board of Weld County Commissioners' authority under the 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, 1999,through May 31, 2000, at specific rates for different types of service. The
County will authorize approved vendors and rates for services only. The Home Based Intensive Family
Intervention Program is a family strength focused home-based services to families in crisis which are time
limited, phased in intensity, and produce positive change which protects children, prevents or ends placement,
and preserves families. This program announcement consists of five parts, as follows:
PART A...Administrative Information PART D...Bidder Response Format
PART B...Background, Overview and Goals PART E...Bid Evaluation Process
PART C...Statement of Work
Delivery Date _
(After receipt of order) BID MUST BE SIGNED IN INK
Dale F. Peterson, M.S.W. , M.H.A.
TYPED OR PRINTED SIGNATURE
VENDOR North Range Behavioral Health _ 1 urwl-on
(Name) Handwritten Signature By Authorized
Officer or Agent of Vender
ADDRESS 1306 11th Avenue TITLE Executive Director
Greeley, CO 80631 DATE 3/10/99
PHONE # (970) 353-3686
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 35
RFP-FYC-99010 Attached A
HOME BASED INTENSIVE FAMILY INTERVENTION PROGRAM BID PROPOSAL AND
REQUEST FOR CONTINUATION OF AWARD UNDER FPP CORE SERVICES FUNDING
FAMILY PRESERVATION PROGRAM
1999/2000 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 1999-2000
BID#RFP-FYC-99010
NAME OF AGENCY: North Range Behavioral Health
ADDRESS: 1306 11th Avenue Greeley, CO 80631
PHONE:J 970) 353-3686
CONTACT PERSON: Patricia Orleans ,- L.C.S.W. TITLE: Director of Children & Family
Services
DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Home Based Intensive Family Intervention
Program is a family strength focused home-based services to families in crisis which are time limited.phased intensity.and
produce positive change which protects children.prevents or ends placement and preserves families
12-Month approximate Project Dates: _ 12-month contract with actual time lines of
Start June 1. 1999 Start
End M:y31.2000 End
TITLE OF PROJECT: Mobile Mental Health Services - Option B
Patricia Orleans , L.C.S.W: 3-/O".SS
Name and Signature of Person Pre paw Document Date
Dale F. Peterson, M.S.W. , M.H.A. thA ir) 3-/,_97
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REOUIREMENTS
For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for
Bid. For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 1998-1999 to
Program Fund year 1999-2000.
Indicate No Change from FY 1998-1999
Project Description
!'farget/Eligibility Populations
ypes of services Provided
)tMeasurable Outcomes _ram
PService Objectives
j' Workload Standards -.
taff Qualifications
Unit of Service Rate Computation
rogram Capacity per Month
ertificate of Insurance
Page 29 of 35
RFP-FYC-99010 Attached A
Date of Meeting(s)with Social Services Division Supervisor: --e-tj-`���z�P� 3-/6 -99
Comments by SSD Supervisor: Z�-0-L 'Y' / U , 1 -ZIT
-
,
l.ti-�7L, .� /L .cam ^> �� ,.,. �.1-/y. /,c-„� �//, -�Cr¢�,di� i -�-,
.�
.-l7�r -,.....z* ../ �-y (�.�r�-._Le{, .ems, , L ,.ems `M a ,( / 1s.,v'Z ,-
1 e
Name and Signature of SSD Supervisor - Date
Page 30 of 35
RFP-FYC-99010
Mobile Mental Health Services-Option B
North Range Behavioral Health
L PROJECT DESCRIPTION
The Mobile Mental Health Services(MMHS or Mobile)offering of North Range Behavioral Health
(N.R.B.H.), formerly the Weld Mental Health Center,has been serving client families for the past
eight years. It meets the requirements of the state defined Home Based Intensive Family Intervention
Program,particularly that known in the past as Option B. It is part of the most intensive offering of
N.R.B.H.'s Family Preservation Team's (FPT) continuum of treatment projects that includes this
service and its more intensive sibling known as Homebuilders(which meets all requirements of the
former Home Based Intensive Family Intervention Program,Option A),the Intensive Family Therapy
Service,and the Sexual Abuse Treatment Service. Its services focus on family strengths and include
work in the areas of problem solving techniques, child management practices, stress management
techniques,and the appropriate use of available resources and support systems. We seek to be able
to continue to offer this service to no fewer than four families at any given time who need, in the
assessment of their Weld County Department of Social Services (W.C.D.S.S.) caseworker, this
moderately high level of care. The service offers a range,on average,of three to five hours of weekly
home-and clinic-based mental health services for up to nine months to each client Family. Due to this
design,Mobile is established for families in crisis who are at risk of having a child placed out of the
family home but who do not present with the severity of a crisis seen in Homebuilders clients but with
more severity than those referred to the Intensive Family Therapy Service. Another factor in
considering Mobile as a treatment alternative is the client family should be seen as in need of extensive
mental health intervention over a relatively prolonged period of time.
Four primary types of treatment services are provided to recipients of Mobile services: therapeutic,
concrete,collateral,and crisis intervention. Each family admitted to the project has a service plan
developed for them that spells out specific services to be delivered in each of these four categories.
The plan describes how a child and his or her family will be treated in order to rapidly respond to and
remedy the crisis in the family that presents the risk of an out-of-home placement of a child occurring
or that precludes the safe return of a child already in placement.
The MMHS concentrates on four overall service objectives in its efforts to achieve the goal of safely
maintaining the child in her or his home or of safely returning the child to her or his home. These
objectives are to improve the family's ability to resolve and manage conflicts within the family, to
improve parental competency,to improve the households management competency, and to improve
the family's ability to gain access to needed resources.
The services of the MMHS are designed to respond to the needs of families with moderate to severe
levels of dysfunction. They provide a clear middle treatment ground between Homebuilders and
Intensive Family Therapy.
IL TARGET/ELIGIBILITY POPULATIONS
The Mobile project is designed to serve at least four Weld County families at any given time. At this
level,no fewer than eight families will be served annually. Referred children may range in age from
birth through 17 years. Whenever feasible and appropriate,all available nuclear family members of
the referred child will be incorporated into the treatment plan as will be those members of her or his
extended family deemed necessary to the treatment process. At least one parent must consent to work
with the project,to protect the child from flintier harm with the goal of maintaining or reunifying the
family. It is anticipated that not fewer than 25%of the client families will require,and will therefore
receive,some level ofbiculhaan ilingual services. Services will be available throughout Weld County
with at least 25%being delivered to families residing in the southern portion of the county. All
families served have arras to 24 hour emergency care seven days per week. In accordance with the
request for proposal's requirements,the monthly maximum capacity ofthe project is four families with
an average monthly capacity of not less than three families. The average length of stay in the project
is six to nine months. Families are provided an average of five hours of care weekly for at least the
first three months of the intervention,followed by the provision of an average of three hours of weekly
care for the remaining six months.
A manageable level of risk of harm to each referred child must exist. Children referred to MMHS
will have met or be at high risk to meet the ow-of-home placement criteria detailed in the request for
proposals.
IIL TYPE OF SERVICES TO BE PROVIDED
All families referred and accepted into the MMHS project receive home-based services for
approximately five hours weekly for the first three months of care and some combination of home-
and clinic-based services for three hours weekly for the remaining six months of care. The exact
combination will be based on the family's needs and will be negotiated with the family and the
W.C.D.S.S.caseworker by the therapist. Service offerings consist of therapeutic,concrete,collateral,
and crisis intervention services. All services are delineated in a service plan tailored to the specific
needs of each client family and designed with the collaboration of the client family and their
W.C.D.S.S. caseworker. Therapeutic services include(when appropriate),but are not limited to,re-
parenting,individual and family therapy,group therapy,support groups,education in problem solving,
lessons in communication skills,and training in parent-child and parent-parent conflict management.
Concrete services include,again when appropriate and not limited to,training in the following areas:
development and enhancement of parenting skills,stress management and reduction,problem solving,
anger and impulse control,budget and general household management, and the planning of family
activities and recreation. Collateral services focus on preparing and teaching families to gain access
to and work constructively with other community agencies whose services would benefit them. Crisis
intervention services,whether provided in the family's home,in the child's school,in the mental health
or other clinic,in other settings,or over the phone,is available on a continual, 24 hour basis. Up to
two hours of case management services are also provided weekly to each family.
Upon receipt of a referral,the Mobile staff contacts the referring W.C.D.S.S. caseworker to begin the
service planning process including the study of all pertinent information about the family. Together,
they establish a plan to introduce the assigned therapist to the family and ensure that the family
understands the nature of the Mobile service and agrees to participate in the service. Family members
are advised of their rights in receiving mental health services,of the obligations their assigned therapist
has in regard to them,and of the credentials of the assigned therapist. Services to the family start at
the first opportunity.
Initially,the Mobile worker will work with the family to assess its strengths and weaknesses. Based
on this gcceeament and input from the caseworker,the service plan,emphasizing the family's strengths,
is further developed and initially implemented. Appropriate releases of information are obtained to
permit the flow of information between those agencies and individuals with whom the family already
interacts and with those whose services the family needs now or will need in the future.
Delivery of the core services outlined above begins,maintaining the emphasis on the strengths of the
family while closely monitoring the safety of the at risk child(ren). Each member of the family is
engaged at an appropriate level given her or his position in the family. Not only are the collective
strengths of the family shored up, the individual strengths of each family member are studied,
enhanced,and utilized in such a manner as to improve the life situation of each member and the family
as a whole.
As the ability of the family to provide safety and security for its members is enhanced,the service plan
is updated to secure the gains made to date, evaluate what is working and what is not working, and
to generally improve the family's capacity to effectively handle the crisis that lead to the initial referral
and to generalize that improvement in the family's general level of functioning.
Psychiatric services including evaluation and the prescribing and monitoring of psychotropic
medications are available to each of the client families as are psychological services such as
psychological testing and evaluation. Access to such services is based on the family's neMs and on
an agreement between the W.C.D.S.S. caseworker and the Mobile mental health worker that the
services are necessary to fulfill the treatment plans that are in effect.
Case management services consisting of referral,linkage,monitoring,advocacy,and service planning
are utilized to maximize each client family's ability to benefit from treatment and to ensure that each
family has access to and receives appropriate services from other agencies.
Mobile services are culturally sensitive and competent. They are designed to be consistent with the
culture and belief systems of the client families. Training to educate and sensitize our staff to the
needs and cultural differences of the residents of Weld County occurs on a regular basis.
IV. MEASURABLE OUTCOMES
Each family member admitted to outpatient services of N.R.B.H. is evaluated at the time of admission
to and discharge from Mobile services using the Colorado Client Assessment Record (CCAR)
developed by the Colorado Office of Mental Health Services. This form provides a wide range of
inquiry into an individual's levels of functioning. The Family Preservation Program Admission and
Termination Evaluation Forms are also to be used as evaluation tools. These look specifically at the
effects of the FPT program. Copies of these fonts are attached at the end of this proposal.
Through the MMHS project, N.R.B.H. enables families with children at risk of out-of-home
placement or who already have children placed out of their homes to care for those children in a
healthful,safe,and nurturing manner in the home environment. Specific goals and objectives are to:
Goal A. Rapidly improve and stabilize family functioning to enable the family to care for the
children in the home setting.
Objective. Provide family preservation services starting within three days of referral to
client families to either prevent out-of-home placements of children and
adolescents in foster and group homes,residential child care facilities,juvenile
detention facilities,and in psychiatric hospitals(family preservation services)
or to return youths from such facilities to their family homes within three
weeks of referral(family reunification services.)
Goal B. Improve the overall functioning of the client families via improved family conflict
management,improved parental competency,improved household management competency,
and an improved ability to gain access to and use appropriate resources in the community to
enable the families to appropriately care for their children in their own homes on a long term
baths.
Objective a Eighty-five percent of the families that successfully complete either family
preservation or reunification services through the Mobile project will measure
significantly lower on the risk aaceccment scales at the time of termination of
services.
Objective b. At discharge,six,and 12 months after the successful termination of services,
90%of the families will remain intact.
Objective c. Seventy-five percent of children currently in long term placement who are
provided reunification services will return to their own homes and not reenter
out-of-home placement within 12 months of completion of services.
Objective d. Fewer than 10%of discharged children will enter another family preservation
service unless such transfer is deemed to be in the best interest of the children.
Objective e. Fewer than 10%of the children served will be in a more costly placement at
discharge and fewer than 15% will be in such a placement six months after
discharge.
Objective f. Eighty percent of the families receiving either family preservation or
reunification services will not have a substantiated incident of abuse or neglect
filed against them during the course of their treatment nor within 12 months
of their successful completion of services.
V. SERVICE OBJECTIVES
In working with families to achieve the goal of improving their abilities to manage family conflict in
a safe, constructive manner, the Mobile worker strives to accomplish the objective of resolving
conflicts between the parents,the children,and the parents and children so that no maltreatment of
the children occurs,no domestic violence occurs,no children run away from home, and no children
commit status or legal offenses. Success in meeting this goal is measured by family,caseworker,and
therapist i..p,.ts concerning the objective. The family will also be asked to report on its subjective
improvements in this area.
To meet the goal of improving overall parental competency,the objective of increasing the parents'
abilities to develop and maintain sound,caring,effective relationships with each other and with their
children is established. An additional objective is to enhance the abilities of the parents to provide as
well as they possibly can for their family's care,nutrition,hygiene, discipline, protection,education,
and supervision. Again,the parents and children will be polled about their subjective opinions about
the improvements they have made as will the therapist and caseworker.
A third service goal of the project is to improve household management competency. The objective
here is to enhance the capacity of the parents to provide a safe household environment for the children
through competently managing the home to include cleaning,repairing, and maintaining the home,
budgeting,and purchasing. Families who do not have a working financial budget develop and adhere
to one with the assistance of the therapist. The family, therapist, and caseworker document the
improvements made in this area.
The fourth service goal of the MMHS is to improve the family's ability,individually and collectively,
to find and use appropriate resources. Treatment and case management services assist the family to
learn more effective means to obtain needed help from other sources in the community and from local,
state, and federal governments. The families will report, and their caseworker and therapist will
confirm, gains in this goal and objective.
VL WORKLOAD STANDARDS
A worker in the Family Preservation Team of N.RB.H. will have a caseload of not more than four
MMHS families at any given time. He or she will provide an average minimum of five hours of direct
family preservation services per family per week for the first three months of care and three hours of
direct family preservation services per family per week for the remainder of the intervention. This
does not include the time required to be spent receiving clinical supervision or in-service training nor
the travel time to reach the families served. Also not included in the hourly averages arc the up to two
hours per week of case management required to assist the family achieve its goals and objectives.
Direct supervision of the Mobile project occurs within the larger FPT. This team is currently designed
to consist of seven individuals:six mental health workers and one administrative supervisor.This will
be modified as much as is feasible to accommodate referrals from W.C.D.S.S.. The ratio of mental
health workers to administrative supervisors will never exceed six to one. The supervisor,Pat Orleans,
MSW,who is also director of the Children and Family Services Program(CFSP)ofN.RB.H. reports
directly to the Executive Director of N.RB.H., Dale F. Peterson, MSW MHA. The supervisor
provides clinical oversight and administration directly to the project as well as clinical supervision to
all newly employed members of the team for at least the first six months of their employment after
which an employee may be permitted to choose a clinical supervisor from among the other qualified
staff of N.RB.H.. Ms. Orleans is clinically supervsed by Larry Pottorff, LCSW. Critical in the
clinical and administrative chains of command,and available for consultation with staff,is N.RB.H.'s
Medical Director,Ted Sills,MD. A board certified child psychiatrist Russ Johnson,MD and two
board certified general psychiatrists,Jim Medelman,MD and Enrique Alvarez,MD,are also available
to consult with the FPT staff and to psychiatrically evaluate family members in need of such services.
Chuck Howard,PhD provides additional consultation to Mobile team members.
The present treatment staff members fully assigned to the FPT are Josephine Lucero,MA LPC, Rich
Hedlund,MA LPC,Jamie Moe-Hartman,MA, and Greg Creed,BA(to receive MA in May, 1999).
Their efforts are augmented by other staff,including Meg Baker,LCSW,Greg Bjork,MA LPC, Lin
Moersen,MSW,Leonor Willis,MA LPC,Ann Richards,MA LPC,and Ave Maria Williams, MSW,
from N.RB.H. when necessary to carry out the service plans of the client families.
VII. STAFF QUALIFICATIONS
All current staff ofN.R.B.H.'a Family Preservation Team exceed,and all those hired in the future will
meet,as a minimum,the qualifications necessary to be a Caseworker III within the state social services
system. All members of the team have either master's degrees in the human services area from
accredited universities and have at least two years experience working with children and families or
have bachelor's degrees in the human services area from accredited universities and have at least five
years experience working with children and families. Due to the use of the team approach, the
members of the team, while specializing in the provision of family preservation services, carry a
diverse caseload in that each may provide a combination of the four different types of family
preservation services offered by N.RB.H.. The equivalent of one full time employee will provide
Mobile services at any given time. All the current staff of the team are trained in risk assessment as
will be any new staff members hired. Any new members hired will be sent to this training, or again
its equivalent, as soon as possible after they begin their employment with us. Psychiatric and
psychological services are delivered by licensed professionals in each of these respective fields
RFP-FYC-99010 Attached A
VIII. COMPUTATION OF DIRECT SERVICE RATE
This form is to be used to provide detailed explanation of the hourly rate your
organization will charge the Core Services Program for the services offered in
this Request for Proposal. This rate may only be used to bill the Weld County
Department of Social Services for direct, face-to-face services provided to
clients referred for these services by the Department. Requests for payment based
on units of service such as telephone calls, no shows, travel time, mileage
reimbursement, preparation, documentation, and other costs not involving direct
face-to-face services will not be honored. Likewise, billings must be for hours
of direct service to the client, regardless of the number of staff involved in
providing those services. Therefore, it is imperative that this rate be
sufficient to cover all costs associated with this client, regardless of the
number of staff involved in providing these services.
(Explanations for these Lines are Provided on the Following Page)
Total Hours of Direct Service per Client 135.25 Hours [A]
Total Clients to be Served 8 clients [B]
Total Hours of Direct Service for Year 1082 Hours [C]
(Line [A] Multiplied by Line [B]
Cost per Hour of Direct Services $ 35.70 Per Hour [D]
Total Direct Service Costs $ 38,627.40 [E]
(Line [C] Multiplied by Line [D] )
Administration costs Allocable to Program $ 14,974.88 [F]
Overhead Costs Allocable to Program $ 20,265.86 [G]
Total Cost, Direct and Allocated, of Program$ 73,868.14 [H]
Line [E] Plus Line [F] Plus Line [G] )
Anticipated Profits Contributed by this Program $ 0 [I]
Total Costs and Profits to be Covered 73,868.14
by this Program(Line [H] Plus Line [I] ) $ _— [J]
Total Hours of Direct Service for Year 1082 [K]
(Must Equal Line [C] )
Rate per Hour of Direct, Face-to-Face Service
to be Charged to Weld County Department of
Social services $ 68.27 [L]
Day Treatment Programs Only:
Direct Service House Per Client Per Month [M]
Monthly Direct Service Rate $ __ [N]
Page 34 of:35
VIII. RATE COMPUTATION: BUDGET DESCRIPTION
Personnel costs are predominant in this budget. The above figures represent the equivalent of one
Hill-time clinical staff member of North Range Behavioral Health(NRBH)working in the Mobile
Mental Health Services to provide the necessary level of additional services called for by the service
plans and the requirements set forth in this proposal,including clinical,case management,support,and
supervisory services. Direct services personnel costs equal$35.70 per direct service hour, or 52%of
the total of S68.27. Supervisory costs are$9.99, or 15%of the total direct time cost. The clerical
support services costs are$3.85,or 6%of the total. The agency overhead of$18.73 amounts to 27%
of the total cost per hour. Psychiatric and psychological services are available at an hourly rate of
$92.56 for those clients needing them and will be billed separately from other clinical costs.
All PAC fiords will be accounted for separately within the overall budget of NRBH. Each project is
regarded as a distinct cost center. NRBH is independently audited annually,including its use of PAC
finds. -
IX. PROGRAM CAPACITY BY MONTH
The MMHS Service-Option B is designed to function with a minimum staff contingent of 1.00FFE,
serving a minimum of four children and their families at any given time throughout the upcoming
fiscal year. NRB.H.will be pleased to accept as many additional families as are determined to need
this level and type of care. We will develop sufficient staffing patterns to accommodate any and all
families needing the MMHS.
ACOptba CERTIFICATE OF INSURANCE 03/09 j99
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Flood & Peterson Ins. Inc . ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. O. Box 578 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
4687 W. 18th Street COMPANIES AFFORDING COVERAGE
Greeley, CO 80632 COMPANY — --
ACNA Insurance
INSURED COMPANY
North Range Behavioral Health El
1306 llth Avenue — -- —
ANY
Greeley, CO 80631 COI'C:
COMPANY
D
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLCY EXPIRATIONUMITS
LTR DATE(MM/DDA'Y) DATE(MM/DDAN)
A GENERALUABIUTY S182327225 01/01/99 01/01/00 GENERAL AGGREGATE 6, 000, 000
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG 6, 000, 000
CLAIMS MADE X OCCUR PERSONALBADV INJURY $1, 000, 000
OWNER'S S CONTRACTORS PROT EACH OCCURRENCE $1, 000, 000
FIRE DAMAGE(My one fire) 60 000
MEDEXP(My one person) 6, 000
A AUTOMOBILE UABIUTY S182327225 01/01/99 01/01/00
ANY AUTO COMBINED SINGLE LIMIT S1, 000 , 000
ALL OWNED AUTOS -BODILY INJURY S
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
- - PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AU TO ONLY
EACH ACCIDENT $
AGGREGATE $
A EXCESS UABIUTY S182327225 01/01/99 01/01/00 EACH OCCURRENCE s2, 000, 000
X UMBRELLA FORM AGGREGATE E, 0 0 O, 000
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND I STATUTCIRI'LIMITS
EMPLOYERS'UABIUTY
EACH ACCIDENT S__
THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT $
PARTNERS/EXECUTNE
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $
A OTHER Prof . Liab. S182327225 01/01/99 01/01/00 $1, 000 , 000 ea. pers .
Claims Made $3 , 000 , 000 total limi
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
Retro date 7/1/86
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
Weld County Placement EXPIRATION DATE THEREOF,TIME ISSUING COMPANY WILL ENDEAVOR TO MAIL
Alternatives Committee 3O _DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
c/o Weld County, Department of BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR UABIUTY
Social Security OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
800 8th Avenue AUTHORIZED REPRESENTATIVE
IGreeley, CO 80631 Fk od+ Peluso" Instaan-cI , rna'
ACORDZ54PI9M)1 of 1 #$100083/M100081 PPM 0ACOR000RPORATION1993
l
t COLORADO CLIENT ASSESSMENT RECORD
II
NAME: a■ GAF SCORE _
I I !AG +� I I IPROGRAMsa ETHNIC/RACE
74
ENCY
American In/ stom
I 1 1 I 1 I 1 1 1 'CLIENT ID ei4 (2)A acifccIIsla der Native
I 1 I 1 1 I I I I !REFERRING AGY, (3)
Black
(4)Hispanic
CLIENT ID isxa (5)White(Non-Hispanic)
I 11 1 I I I 1 !MEDICAID ID goer Muni-Racial
HISPANIC ORIGIN is ;.:_
I 1 I I 1 1 1 !ADMISSION DATE 1340 (1)Not of Hispanic Origin
MONTH DAY YEAR (2)Mexican/Mexican-American
(3)Puerto Rican
I I ! gCT1ON TYPE (Manual Input Only) 41a2 (4)Cuban
01=Admission 11orrection to 5 Other His..nio
=C
02=Activate 12=Correction to Activation MARITAL STATUS
03=Updatete 1e 3 Correction to Update (1)Never Married (4)Widowed is0Correction to Inactivation
0066=E Only Divorced
Discharge 15=Correction to Discharge (3)Mart Separated(Le Married gal Marital Discord)
PLACE OF RESIDENCE n
MEDS ONLY CLIENT 43 (1)Correctional Facility/Jail !
(1)Yes (2)No (2)Inpatient
ADMISSION STATUS (3)Nursing Home
44 (4)Residential Facility-Mental Health
(1)New Admission (5)Residential Facility-Non- Mental Health
(2)Readmission From This Fiscal Year (6)Boarding Home
(3)Readmission From Prior Fiscal Year (7)Homeless-In
O Shelter
PERMANENT HANDICAPRMPAIRMENT 45-49 (8)Homeless-On the Street
(Code J 5 Beast Using 1 Yes 2 No) _ (9)Other Independent Living Arrangement
(1)Mental Retardation CURRENT LIVING ARRANGEMENT is
(2)Deafness or Severe Hearing Loss (1)Lives With Both Parents
(3)Blindness or Severe VisualImpairment Impaent (2)Lives With One Parent
(4)Speech Impairment (3)Lives WAh Spouse and or Other Relative(s)
(4)Lives Alone
(5)Non-Ambulatory or Assisted Ambulation _ (5)Lives With Unrelated Person(s) _
LEGAL STATUS CURRENT EMPLOYMENT STATUS rs I
50
(1)Voluntary (1)Employed-Full Time
(2)Court-Directed Voluntary (2)Employed-Part lime
(3)Forensic Involuntary (3)Homemaker-Not Otlnenvlse Employed
(4)72-Hour Evaluation and Treatment(MH-HOLD) (4)Sheltered Employment
(5)Short-Term Citified (5)Not in Labor Force
(6)Long-Term Certified (6)Unemployed For Less Than 3 Months
(7)Voluntary Hospitalization of Minors (7)Unemployed For 3 Months or More
(8)Chlldrens'Code C.R.S.19-1-101 (8)Armmned Forces(Active Military Duty)
(9)EmergAnvol.A ldohpltsn.Drug Commitment ANNUAL FAMILY HOUSEHOLD INCOME MU
.... . REFERRAL SOURCE s+42 I I I I
PRIMARYDIAGNOSIS SECONDARY DIA NOSIS T NUMBER OF PERSONS SUPPORTED BY es
(if spout* 534
I I I •I I I IIIII II THIS INCOME(Include Client)
I PRESENTING PROBLEM HAS EXISTED m (2)2(client only) (6)6
( )2 (7)7
(1)1 Year or Longer (2)Less Than 1 Year (33)3 (8)8
PREVIOUS MENTAL HEALTH SERVICES 5942 _ (5)5 (9)9 or Mae
(Code eja,Four Bores Using 1 Yes 2 No)
Inpatient Care HIGHEST EDUCATION LEVEL-IN YEARS seer I
Other 24-Hour Care _ flea First sm Grade Code as 00)
Partial Care DUE TO MENTAL HEALTH REASONS, n
Outpatient Care CLIENT IS CURRENTLY RECEIVING;
! 1 COUNTY OF RESIDENCE (1)SSI (3)Both
gas (2)SSDI (4)Neither
DATE OF BIRTH 77 esn FIRST 3 LETTERS OF CLIENTS LAST NAMEraan 1 I
` ..,. 1 .l ZIP CODE
MONTH DAY YEAR net n-+so
SEX I I I l l -1 1 1
73
Triage Denver Health&Medical Center Only +on
(1)Male (2)Female
White—Billing Yelle.e—eh ..r SHAt1E71 DrfYao so=s nt m..w.-a...-.......... __
I COLORADO CLIENT ASSESSMENT RECORD 2
I
Client I.D. Name Admit Date
HISTORY 102-1oe Check ALL that Apply CURRENT P-SEV Check ALL Problems that Apply
Vict:_ Sewal Abuse Hist:Suicide Attempt _His!:Unstable Employrn C] AGGRESSIVENESS 111.497
_Val:Physical Abuse Hist:Family Merit-III
Neglect Hist:Family Sub-Abuse _Vol: Min7 Out _Defiant _
_ _ Threatening
Aggresive Hostile Intimidating
SPECIAL PROBLEMSIISSUES to9-11s Check ALL that Apply i � IA
nSOCL
� — - Sti-203
—Learning DisabilityCNS Disorder _Language Issues Disres — —
-Eating Disorder Fire Set/Destroy Property _Disobedient _Dishonest
PROBLEM SEVERITY CI LEGAL 204-210
Legal Problems Probations/Parole Offenses:Plupv,ty
RATE the CURRENT P-SEV(PROBLEM SEVERITYI _-_Charges Pending _Offenses:Substances = Per
sons
for each area in the boxes provided,using the following scale:
None Slight Moderate Severe Extreme CI VIOLENCE/DANGER TO OTHERS 211-217
1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 Violent _Homicidal ideation
__
__Assaullive _Homicidal Threat/Attempt
CURRENT P-SEV Check ALL Problems that Apply __Phys/Sexual Abuser _Danger to Others ] itolMDj
EMOTIONAL WITHDRAWAL 117-In LJ^^ FAMILY ISSUES 2+c22s
Underactive Passive _Doesn't Verbalize Feelings
Distant Subdued Blunted Affect No Family/No Contact Family Legal Domestic Valence
- Out of Home Placement Parenting Unstable Home/Fam
DEPRESSION +24-+so _____
— —
—Depres _Lonely Hopeless 1-1 FAMILY PROBLEMS WITH 226-23+
Worthless Sad Dejected
— — Parent Partner _Relative
ANXIETY tst-+u __--
Sibling _Child
Anxious _Nervous _Panic n] INTERPERSONAL PROBLEMS 232-236
Tense Flashbacks Phobic
Fearful Nightmares/Terrors __w/Friend _Establishing Relationships
HYPER AFFECT 1s0-+46 __Social Skills —Maintaining Relationships
_Overactive _Pressured Speech _Elevated Mood p] ROLE PERFORMANCE(Work/Schooll 237-243
Mood Swings Accelerated Speech Mania
— Absenteeism Performance Behavior
ATTENTION PROBLEMS 147-153 --_ ucpensmro Suspension/Probation _Termination _Limited Employability
_Agitated _Distractible Mention Span pi SUBSTANCE ABUSE 244-249
Restless Impulsive Concentration
— Problem w Alcohol —Interferes
In Recovery
SUICIDE/DANGER TO SELF 154.160 --Problem w Drugs _Interferes with Responsibilities
_Suicide Ideation Self-lnjury/Mutilation C] MEDICAL/PHYSICAL 2ea255
Suicide Plan Reddest Self-Endangermenl
—Suicide Attempt —Danger to Self (cRB R71W __Acute Illness —Medial Care Needed —Physical Handicap
Chronic Illness InjuryByAbuse/Assauh Permanent Disability
THOUGHT PROCESSES ill-lee
CII SECURITY/MANAGEMENT ISSUES 257-265
Bizarre Suspicious Repeated Thought
_ _ _
_Delusions Paranoid Obsessive Seclusion/Time Out Walkaway/Escape Behavior Managemt
Hallucinations Close Supervision Severity Suicide Watch
Medication Compliance Inadequate Mutt Supervision
COGNITIVE PROBLEMS +6s-17s -- —
Confused _Loose Associations Lacks Self Awareness OVERALL DEGREE OF PROBLEM SEVERITY 266
_-Disoriented _Disorganized Impaired Judgement Check ONE Response
SELF-CARE/BASIC NEEDS ne-tn None Slight Moderate Severe Extreme
Hygiene DoesntM7nage Money Doesn't Provide Food I 2 3 4 5 6 7 8 9
Self Care Problems Doesn't Use Resources Doesn't Provide Housing
Gravely Disabled x !io UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL PROBLEM SEVERITY 267
RESISTIVENESS u 114lao Check ONE Response
Resistive _Evasive Wary Much Much
_Uncooperative _Guarded _Denies Problems Better Better No Change Worse Worse
-1 2 -3 4 5 - 6 7 8 9
I COLORADO CLIENT ASSESSMENT RECORD 3 1
Client I.D. Name Admit Date
STRENGTHS/RESOURCES (� LEVEL-OF-FUNCTIONING (LOF)
Check ALL OURRENT STRENGTHS I RESOURCES Individual has: I Cheek ONE Response for Each LOF Area
ECONOMIC RESOURCES 214S-271 SOCIETAL/ROLE FUNCTIONING 304
Medicaid/Medicare Employment Transportation Very High Moder High Average Moder Low Very Low
_Other Medical Insw —_Haring Function Function Function Function Function
_Other Public Assist _Fknncial
EDUCATION/SKILL RESOURCES 275-279 1 2 3 4 5 6 7 a y
INTERPERSONAL FUNCTIONING 303
Language Sldlls Skills Intelligence
Education _Job SHlls Very High Moder High Average Moder Low Very Low
— — Function Function Function Function Function
PERSON RESOURCES no-ni _ _
_Parent(s) _Partner _Professional Caregiver 1 2 3 4 5 6 7 8 9
Sibliing(s) Child(ren) _Other Supportive Relationship DAILY LIVING/PERSONAL CARE FUNCTIONING 308
_Relatie(s) _Friend(,) Very High Moder High Average Moder Low Very Low
PERSONAL STRENGTHS maml Function Function Function Function Function
Likeableness _Emotional Stability _Adaptability 1 2 3 4 5 6 7 6 9
Appearance Thought Health Clarity_ PHYSICAL FUNCTIONING 307
—ConfMaae _Hopefulness _Resourcefulness Very High Moder High- Average Moder Low Very Low
Jud—Empathy Responsibility
—Empathy —Toleronca Function Function Function Function Function
Insight
1 2 3 4 5 6 7 8 9
COGNITIVE/INTELLECTUAL FUNCTIONING 30e
Very High Moder High Average Moder Low Very Low
Function Function Function Function Function
1 2 3 4 5 6 7 8 —9--
CURRENT OVERALL STRENGTHS/RESOURCES 302 OVERALL LEVEL OF FUNCTIONING Check ONE Response 309
Check ONE Response
Very High Moder High Average Moder Low Very Low
Very High High Moderate Some Very Low Function Function Function Function Function
1 2 3 4 5 6 7 8 9 • 1 2 3 1 5 6 7 8 9
UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL STRENGTHS/RESOURCES 303 CHANGE IN LEVEL OF FUNCTIONING Check ONE Response 310
Check ONE Response Much Much
Much Much Better Better No Change Worse Worse
Better Better No Change Worse Worse -
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
I I I I STAFF ID 311d19 STAFF SIGNATURE
❑ DISCIPLINE' 1=none 2=mh worker 3=nursing 4=social work 5=psychology 6=psychiatry 7=other 320
r] DEGREE' 1=none 2=associate 3-bachelors 4=masters 5=PhD/PsyD/EdD 6=MD 7=other 324
COMPLETE THIS BOX ONLY FOR COMPLETE THIS BOX ONLY AT DISCHARGE
UPDATE,ACTIVATE AND INACTIVATE STATUS C
DATE FORM COMPLETED
MONTH DAY YEAR 330-337
C EL] LAST CONTACT DATE
MONTH DAY YEAR 1'18 344
EFFECTIVE DATE 322-329 C EC] I QISCHARGE DATE
MONTH DAY YEAR MONTH DAY YEAR 316353
C] TYPE OF TERMINATION' 331
SPECIAL STUDIES 1aDischarged/Transfened 5-From Inactive
2-TX Completed/No Referral 6•Patient/Client Died
]e7 3-TX Completed/Follow-up 7-Patient/Client Terminated
MEvaluation Only
397a76 C I TERMINATION REFERRAL* 335a59
NOTE:Use 61 'Self' f no Referral
FAMILY PRESERVATION PROGRAM ADMISSION EVALUATION FORM (7/97)
Client Name _ Client Id*
Diagnosis: Primary Secondary
Date of Birth School Grade City
Admit Date Center
Medicaid _ Yes _ No (Check One) Sex _ Ethnicity
Who had custody of youth at time of referral to FPP
Where was youth residing at time of admission to FPP (Be specific)
Date of initial referral for FPP services
Date of first contact by FPP therapist
FPP Therapist
Previous mental health services (explain)
Special Behaviors or Circumstances/Reasons for referral
PAST PRESENT
Yes No Yes No
Suicidal
Violence toward others
Runaway Behavior
Social Isolation
Legal Charges
Domestic Violence
On Probation
Victim Physical Abuse
Victim Sexual Abuse
Alcohol Use
Use of Inhalants
Other Drug Use
Learning Disabilities
Special Education
Bed Wetting _
Encorpresis
Others (specify
GAF SCORE AT ADMISSION TO FPP
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNCTIONING SCORES AT ADMISSION TO FAMILY PRESERVATION PROGRAM
(RATE ALL SIX AREAS)
High Moder. Aver. Moiler. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
SOCIETAL FUNCTIONING
INTERPERSONAL FUNCTIONING
DAILY LIVING PERSONAL CARE
PHYSICAL FUNCTIONING
COGNITIVE INTELLECTUAL
OVERALL LEVEL OF FUNCTIONING
FAMILY PRESERVATION PROGRAM TERMINATION EVALUATION FORM (7/97)
Client Name Client Idtt
Discharge date fran FPP
List all different types of FPP services used
Discharge Diagnoses: Primary Secondary
Who has custody of child at time of termination fran FPP?
Where was child living immediately after termination fran FPP?
Who will follow youth after discharge?
Special Behaviors or Circumstances
PRESENT
Yes No
Suicidal
Violence toward others
Runaway Behavior
Social Isolation _ ---
Legal Charges _ ---
On Probation _ ---
Victim Physical Abuse _ ---
Victim Sexual Abuse - ---
Alcohol Use _ ---
Use of Inhalants
Other drug use - ---
Learning Disabilities
Special Education _
Bed Wetting _
Encorpresis
Domestic Violence - ---
Others (specify) _
GAF SCORE AT DISCHARGE _
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNCTIONING SCORES AT DISCHARGE FROM FAMILY PRESERVATION PROGRAM
(RATE ALL SIX AREAS)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
SOCIETAL FUNCTIONING
INTERPERSONAL FUNCTIONING
DAILY LIVING PERSONAL CARE
PHYSICAL FUNCTIONING
COGNITIVE INTELLECTUAL _
OVERALL LEVEL OF FUNCTIONING
fc
North Range
Behavioral Health l i i I
May 19, 1999
Judy A. Griego, Director
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
Re: RFP Recommendations and Conditions
Dear Ms. Griego:
The purpose of this letter is to respond to the recommendations and conditions specified in
your letter of May 14, 1999.
Intensive Family Therapy (RFP 99008)
I. Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (b)
Payment will be denied to IFT providers for any charges submitted foe therapy 45 minutes
or less unless cleared by explanation and approved by the program area supervisor.
NRBH Response: (a) IFT providers will receive further training and closer supervision, in
order to insure that quarterly reports are made in a timely manner. (b) This condition is
understood and it will be communicated to the appropriate IFT and billing personnel.
Option B (RFP 99010)
2. Recommendation: The program should be goal oriented. This program does receive
more than eight referrals a year.
NRBH Response: Close supervision will take place in order to insure that the program
remains oriented toward fulfilling the goals expressed in the proposal. The Option B
Program will be prepared to accept significantly more than eight referrals, as needed.
/ ('U Rf 4 l /10701 3I534468r/ Fax(070)3,3-3906
Option B (RFP 99010) continued
2. Condition: Submit timely quarterly reports to caseworkers and offer more flexibility
with time frames for clients.
NRBH Response: Option B providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner. Additionally, closer
supervision and the further addition of potential providers will allow more time frame
flexibility.
Sex Abuse Treament (RFP 99007)
3. Recommendation: Submit timely quarterly reports to caseworkers.
NRBH Response: Treatment providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner.
Day Treatment (RFP 99006)
4. Recommendation: The caseworker shall be involved in the assessment process.
NRBH Response: The is little doubt that the involvement of the caseworker is a necessity
in the assessment process. Closer supervision will occur to insure that greater efferts are
made to contact and communicate with caseworkers during tha assessment process.
If you have any further concerns or questions please let us know and we will address them
as quickly and effectively as possible.
Sincerely,
Cha s A. Howard, h.D.
Director of Children and Family Services
90
Dale F. Peterson, M.S.W., M.H.A, Director
North Range Behavioral Health
sr/Misr)] . A
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
' GREELEY, CO 80632
Administration and Public Assistance(970)352-1551
C Child Support(970) 352-69331
Protective and Youth Services(970)352-1923
COLORADO May 14, 1999
Mr. Dale Peterson, Director
North Range Behavioral Health, Inc.
1306 11 Avenue
Greeley, CO 80361
Dear Mr. Peterson:
Re: RFP 99008 (IFT) Intensive Family Therapy
RFP 99010 Option B -
RFP 99007 Sex Abuse Treatment
RFP 99006 Day Treatment
Dear Mr. Peterson:
The purpose of this letter is to outline the results of the RFP Bid process for PY1999-2000 and to
request written information or confirmation from you by May 20, 1999.
A. Results of the RFP Bid Process for PY1999-2000
On April 7, 1999, the Families, Youth and Children (FYC) Commission approved the
RFP(s) listed above for inclusion on our vendor list. The FYC Commission attached the
following recommendations and/or conditions regarding your RFP bid(s).
1. RFP 99008, Intensive Family Therapy:
Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (b)
Payment will be denied to Intensive Family Therapy providers for any charges
submitted for therapy 45 minutes or less unless cleared by explanation and
approved by the program area supervisor.
2. RFP 99010, Option B:
Recommendation: The program should be goal oriented. This program does
receive more than eight referrals per program year.
Condition: Submit timely quarterly reports to caseworkers and offer more
flexibility with time frames for clients.
Page 2
North Range Behavioral Health/May 14, 1999
3. RFP 99007, Sex Abuse Treatment:
Recommendation: Submit timely quarterly reports to caseworkers.
4. RFP 99006, Day Treatment:
Recommendation: The caseworker shall be involved in the assessment process.
B. Required Response by RFP Bidders Concerning FYC Commission
Recommendations and Conditions.
The Weld County Department of Social Services is requesting your written response to
the FYC Commission's recommendations and conditions. Please respond in writing to
David Aldridge, Weld County Department of Social Services, P.O. Box A, Greeley, CO,
80632, by May 20, 1999, close of business, as follows:
1. FYC Commission Recommendations:
You are requested to review the FYC Commission recommendations and to:
a. accept the recommendation(s) as written by the FYC Commission; or
b. request alternatives to the FYC Commission's recommendation(s); or
c. not accept the recommendation(s) of the FYC Commission.
Please provide in writing how you will incorporate the recommendation(s) into your
bid. If you do not accept the recommendation, please provide written reasons why.
All approved recommendations under the NOFAA will be monitored and evaluated
by the FYC Commission.
2. FYC Commission Conditions:
All conditions will be incorporated as part of your RFP Bid and Notification of
Financial Assistance Award (NOFAA). If you do not accept the condition(s), you
will not be authorized as a vendor unless your mitigating circumstances are accepted
by the FYC Commission and the Weld County Department of Social Services. If you
do not accept the condition, you must provide in writing reasons why. A meeting will
be arranged to discuss your response. Your response to the above conditions will be
incorporated in the RFP Bid and Notification of Financial Assistance Award.
Page 3
North Range Behavioral Health/May 14, 1999
If you wish to arrange a meeting to discuss the above conditions and/or recommendations, please
do so through Elaine Furister, 352.1551, extension 6295, and one will be arranged prior to May
20, 1999.
Sincerely, a
J it A. 5nego, D recto
d County Department of Social Services
cc: Mike Hoover, Chair, FYC Commission
David Aldridge, Social Service Manager II
JG:ef
Weld County Department of Social Services
Notification of Financial Assistance Award
for Families, Youth and Children Commission (Core) Funds
Type of Action Contract Award No
X Initial Award FY99-PAC-2002
Revision (RFP-FYC-99008)
Contract Award Period Name and Address of Contractor
North Range Behavioral Health
Beginning 06/01/1999 and Intensive Family Therapy Program
Ending 05/31/2000 1306 1lth Avenue
Greeley, CO 80631
Computation of Awards DescriptiQQl
Unit of Service The issuance of the Notification of Financial Assistance
Award is based upon your Request for Proposal (RFP).
The service offers an average of 3 hours weekly of The RFP specifies the scope of services and conditions
home-and clinic-based mental health services for of award. Except where it is in conflict with this
up to 26 weeks to each client family, monthly NOFAA in which case the NOFAA governs, the RFP
program capacity of 15. Four primary types of upon which this award is based is an integral part of the
treatment services are provided to recipients of action.
IFT services: therapeutic, collateral, and crisis
intervention. Special conditions
Cost Per Unit of Service 1) Reimbursement for the Unit of Services will be based
on an hourly rate per child or per family.
Hourly Rate Per $ 68.27 2) The hourly rate will be paid for only direct face to face
Unit of Service Based on Average Capacity contact with the child and/or family or as specified in
the unit of cost computation.
3) Unit of service costs cannot exceed the hourly and
Err : yearly cost per child and/or family.
.Signed RFP:Exhibit A 4) Payments will only be remitted on cases open with,and
Supplemental Narrative to RFP: Exhibit B referrals made by the Weld County Department of
�Recommendation(s) Social Services.
✓Conditions of Approval 5) Requests for payment must be an original submitted to
the Weld County Department of Social Services by the
end of the 25'h calendar day following the end of the
month of service. The provider must submit requests
for payment on forms approved by Weld County
Department of Social Services.
Ap Is: Program Official:
By Bye --
Dale K. Hall, Chair Judy A. riego Director
Board of Weld County Commissioners Weld unty epartment of Social Services
Date: o /o 3i 99 Date: 6i02 1199
INVITATION TO BID
DATE: February 26, 1999 BID NO: RFP-FYC-99008
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-99008) for: Family Preservation Program--Intensive Family Therapy
Program Family Issues Cash Fund or Family Preservation
Program Funds
Deadline: March 23, 1999, Tuesday, 10:00 a.m.
The Placement Alternatives Commission, an advisory commission to the Weld County Department-of Social
Services, announces that competing applications will be accepted for approved vendors pursuant to the Board
of Weld County Commissioners authority under the 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 Placement Alternatives Commission wishes to approve services targeted to run
from June 1, 1999,through May 31, 2000, at specific rates for different types of service,the County will
authorize approved vendors and rates for services only. The Intensive Family Therapy Program must provide
for therapeutic intervention through one or more qualified family therapists,typically with all family members,
to improve family communication, function, and relationships. This program announcement consists of five
parts, as follows:
PART A..Administrative Information PART D_.Bidder Response Format
PART B...Background, Overview and Goals PART E....Bid Evaluation Process
PART C...Statement of Work
Delivery Date -
(After receipt of order) BID MUST BE SIGNED IN INK
Dale F. Peterson, M.S.W. , M.H.A.
TYPED OR PRINTED SIGNATURE
1)1
VENDOR North Range Behavioral Health 1ioAc i w � w�
(Name) ]Handwritten Signature By Authorized
Officer or Agent of Vender
ADDRESS 1306 llth Avenue TITLE Executive Director
Greeley, CO 80631 DATE 3/10/99 _
PHONE # (970) 353-3686
The above bid is subject to Terms and Conditions as attached hereto and incorporated.
Page 1 of 35
•
•
RFP-FYC-99008 Attached A
INTENSIVE FAMILY THERAPY PROGRAM BID PROPOSAL
FAMILY PRESERVATION PROGRAM
1999/2000 BID PROPOSAL APPLICATION
PROGRAM FUNDS YEAR 1999-2000
BID#RFP-FYC-99008
NAME OF AGENCY: North Range Behavioral Health
ADDRESS: 1306 11th Avenue Greeley, CO 80631
PHONE:f 970) 353-3686
CONTACT PERSON: Patricia Orleans, L.C.S.W. TITLE: Director of Children & Family
Services
. DESCRIPTION OF FAMILY PRESERVATION PROGRAM CATEGORY: The Intensive Family Therapy Program must
provide for therapeutic intervention through one or more,qualified family therapists.typically with all family members.to
improve family communication.functionine.and relationships
12-Month approximate Project Dates: _ 12-month contract with actual time lines of:
Start June 1. 1999 Start
End May 31- 1999 End.
TITLE OF PROJECT: Intensive Family Therapy
Patricia Orleans , L.C.S.i4: �� �� ?_"a • 29
Name and Signature of Person Preppnn' gment Date
Dale F. Peterson, M.S.W. , M.H.A. O \ 3 _99
Name and Signature Chief Administrative Officer Applicant Agency Date
MANDATORY PROPOSAL REOUIREMENTS
For both new bids and renewal bids,please initial to indicate that the following required sections are included in this Proposal for
Bid.For renewal bids,please indicate which of the required sections have not changed from Program Fund Year 1998-1999 to
- Program Fund Year 1999-2000.
Indicate No Chaneg from FY 1998-1999
C- 5Project Description _
( TTarget/Eligibility Populations C ��
ypes of services Provided
- easurable Outcomes C
ervice Objectives c _
orkload Standards
-
Staff Qualifications _
nit of Service Rate Computation _
-,1,141rogram Capacity per Month
-
Certificate of Insurance
Page 29 of 35
RFP-FYC-99o08 Attached A
Date of Meeting(s)with Social Services Division Supervisor: i �v\eV ?-Jo-`,
Comments by SSD Su ervis ��c�'ti
1,,�' i'
J /
it* % a t
Can
Name and Signature of SSD Supervisor Date
Page 30 of 35
RFP-FYC-99008
Intensive Family Therapy
North Range Behavioral Health
L PROJECT DESCRIPTION
The Intensive Family Therapy(11.1)service of North Range Behavioral Health(N.RB.H.), formerly
the Weld Mental Health Center,has been serving client families for the past eight years. It is the least
intensive offering of N.RBIt's Family Preservation Team's(FPT)continuum of treatment projects
that includes Homebuilders,the Mobile Mental Health Service(Option B),and the Sexual Abuse
Treatment service. Its services focus on family strengths and include work in the areas of problem
solving techniques,child management practices,stress management techniques,and the appropriate
use of available resources and support systems. We seek to be able to continue to offer this service
to at least 20 families at any given time who need,in the assessment of their Weld County Department
of Social Services(W.C.D.S.S.)caseworker,this level and type of care. The service offers an average
of three hours weekly of home-and clinic-based mental health services for up to 26 weeks to each
client family. If the family needs an extended period of similar services to reach its objectives,a 26-
week extension,if approved,will be provided with the level of services matched to the needs of the
family as negotiated between the family,the caseworker,and the therapist. The actual extension will
be jointly agreed upon by the family, the IFT worker, and the W.C.D.S.S. caseworker pending
approval orate plan by a W.C.D.S.S. internal agency review and by W.C.D.S.S. administration. The
W.C.D.S.S. caseworker will document the reason for extension in the family's case record.
Four primary types of treatment services are provided to recipients of IFT services: therapeutic,
concrete, collateral, and crisis intervention. Each family admitted to the project will have a
comprehensive services plan developed for them that spells out the specific services to be delivered
in each of these four categories. The plan describes how a child and his or her family will be treated
in order to rapidly respond to and remedy the crisis in the family that presents the risk of an out-of-
home placement of a child occurring or which precludes the safe return of a child already in
placement.
IFT services will concentrate on four service objectives in our efforts to achieve the goal of safely
maintaining the child in her or his home or of safely returning the child to her or his home. These
objectives are to improve the family's ability to resolve and manage conflicts within the family,to
improve parental competency,to improve the households management competency, and to improve
the family's ability to gain mess to needed resources.
IFT workers use a wide variety of interventions to accomplish the goals negotiated with the client
family. A majority of the time in treatment will be spent in family therapy with smaller amounts in
individual therapy. Individual sessions are often used to help an individual to accelerate the rest of the
treatment process or to focus efforts to break a therapeutic impasse.
IL TARGET/ELIGIBILITY POPULATIONS
The monthly capacity of the IFT is at least 20 families with an average monthly capacity of 15
families. The IFT will accept as many additional families as need this level of care. Each family will
receive an average of three hours of direct care weekly. While IFT services will be available for up
to 12 months,we will work to achieve an average length of stay in the project of six months. Not less
than 40 families will be served annually given this average length of stay. Referred children will range
in age from birth through 17 years. All available and appropriate nuclear family members of the child
and those members of her or his extended family deemed necessary to the treatment process will be
incorporated into services. At least one parent must consent to work with the project with the goal
of maintaining or reunifying the family. It is anticipated that up to 25%of the families will require,
and therefore will receive, some level of bicultural/bilingual services. Services will be available
throughout Weld County with at least 25%being delivered to families from the southern portion of
the county. All families will have access to emergency services 24 hours per day, seven days per
week. -
An initial assessment will determine if a referred family is capable of having a child in placement at
the time of referral return home within three months of services initiation,if there is a reasonable
possibility that services can bring about sufficient improvement in parental competency to allow a child
to safely reside at home or return home, and if a manageable level of risk of hann to each referred
child exists. Children referred will meet or be at high risk to meet the out-of-home placement criteria
stated in the request for proposals.
III. TYPE OF SERVICES TO BE PROVIDED
All families referred and accepted into IFT services will receive home-and clinic-based as appropriate.
It is anticipated that services will initially be offered in the clients'homes with a gradual transition to
the clinic as the families become increasingly competent. All services will be delineated in a service
plan tailored to the specific needs of each client family and designed with the collaboration of the
client family and their W.C.D.S.S. caseworker. Each family will be provided therapeutic, concrete,
collateral, and crisis intervention services.
Therapeutic services will include(when appropriate),but not be limited to individual and family
therapy,education in problem solving,lessons in communication skills,and training in parent-child
and parent-parent conflict management. IFT services,designed to capitalize on existing individual and
collective strengths within the family and to empower families, focus on resolving conflicts and
disagreements within the family,specifically those that are contributing to child maltreatment,running
away,and to the behaviors constituting status and legal offenses. Co-therapy,using the services of
other qualified family therapists as co-facilitators,will be used when necessary to accomplish the
family's goals in treatment.
Psychiatric services including evaluation and the prescribing and monitoring of psychotropic
medications are available to each of the client families as are psychological services such as
psychological testing and evaluation. Access to such services will be based on the family's needs and
on an agreement between the W.C.D.S.S. caseworker and the IFT mental health worker that the
services are necessary to fulfill the treatment plans that are in effect.
Concrete services will include,when appropriate and not limited to,training of the family in the areas
of development and enhancement of parenting skills, stress management and reduction,problem
solving,anger and impulse control,budget and general household management,and the planning of
family activities and recreation.
Collateral services will focus on preparing and teaching families to gain access to and work
constructively with other community agencies whose services would benefit them. They will be paired
with the case management services that will be provided as needed by each family. These services
consist of referral,linkage,monitoring,advocacy,and service planning. They are utilized to maximize
each client family's ability to benefit from treatment and to ensure that each family has access to and
receives appropriate services from other agencies.
Crisis intervention services,whether provided in the family's home,in the child's school,in the mental
health or other clinic,in other settings,or over the phone,will be continually available. These services
will be provided by both the assigned IFT therapist and by the emergency system of N.R.B.H.
Upon receipt of a referral,the IFT staff will contact the referring W.C.D.S.S. caseworker to begin the
service planning process including the study of all pertinent information about the family. 'Together,
they will establish a plan to introduce the assigned therapist to the family and ensure that the family
understands the nature of the IFT service and agrees to participate in the service. Family members
will be advised oftheir rights in receiving mental healthcare,of the obligations their assigned therapist
has in regard to them,and of the credentials of the assigned therapist Services to the family will start
at the first opportunity.
Initially,the IFf worker will work with the family to access its strengths and weaknesses. Based on
this assessment,the service plan,emphasizing the family's strengths,will be further developed and
initially implemented. Appropriate releases of information will be obtained to permit the flow of
information between those agencies and individuals with whom the family already interacts and with
those whose services the family will need.
The delivery of the core services outlined will maintain this emphasis on the strengths of the family
while closely monitoring the safety of the at risk child(ren)occurs. Each member of the family is
engaged at an appropriate level given her or his position in the family and developmental readiness.
Not only are the collective strengths of the family shored up,the individual strengths of each family
member are studied,enhanced,and utilized in such a manner as to improve thelife situation of each
member and the family as a whole. The IFT therapist continually reassesses her or his intervention
to determine what other services may be necessary to enhance the family's abilities to achieve its goals.
As the ability of the family to provide safety and security for its members is enhanced,the service plan
is updated to secure the gains made to date,to evaluate what is working and what is not working,to
generally improve the family's capacity to effectively handle the crisis that lead to the initial referral
as well as other crises the family may encounter, and to generalize that improvement across the
family's general level of functioning.
The IFTs services are culturally sensitive and competent. They are designed, as much as is possible,
to be consistent with the culture and belief systems of the client families. Training to ednrate and
sensitize our staff to the needs and cultural differences of the residents of Weld County occurs on a
regular basis.
•
IV. MEASURABLE OUTCOMES
Each family member admitted to outpatient services of N.RB.H. is evaluated at admission and at
discharge from IFT services using the Colorado Clinical Assessment Record(CCAR)developed by
the Colorado Office of Mental Health Services. This form provides a wide range of inquiry into an
individual's levels of functioning. The Family Preservation Program Admission and Termination
Evaluation Forms are also to be used as evaluation tools. These look specifically at the effects of the
FPT program. Copies of these forms are attached at the end of this proposal.
Through the 1FT project,N.RB.H. works to enable families with children at risk of out-of-home
placement or who already have children placed out of their homes to care for those children in a
healthful,safe,and nurturing manner in the home environment Specific goals and objectives are to:
Goal A. Rapidly improve and stabilize family functioning,in a cost efficient manner relative
to out-of-home placement costs,to enable the family to care for the children in the home
setting.
Objective a. Provide family preservation services starting within three days of referral to
client families to either prevent out-of-home placements of children and
adolescents in foster and group homes,residential child care facilities,juvenile
detention facilities,and in psychiatric hospitals(family preservation services)
or return youths from such facilities to their family homes within three months
of referral(family reunification services.)
Objective b. Provide these services in a cost efficient manner so that the cost of the 1FT
intervention is less than the cost of the out-of-home placement it displaced.
Goal B. Improve the overall functioning of the client families via improved family conflict
management,improved parental competency,improved household management competency,
and an improved ability to gain access to and use appropriate resources in the community to
enable the families to appropriately care for their children in their own homes on a long term
basis.
Objective a. Eighty-five percent of the families that successfully complete either family
preservation or reunification services through the 1FT project will measure
significantly lower on the risk assessment scales at time of termination of
services.
Objective b. At discharge, six,and 12 months after the successful termination of services,
90%of the families will remain intact.
Objective c. Seventy-five percent of children currently in long term placement who are
provided reunification services will return to their own homes and not reenter
out-of-home placement within 12 months of completion of services.
Objective d. Fewer than 10%of discharged children will enter another family preservation
service unless such transfer is deemed to be in the best interest of the children.
Objective e. Fewer than 10%of the children served will be in a more costly placement at
discharge and fewer than 15%will be in such a placement six months after
discharge.
Objective f Eighty percent of the families receiving either family preservation or
reunification services will not have a substantiated incident of abuse or neglect
filed against them during the course of their treatment nor within 12 months
of their successful completion of services.
V. SERVICE OBJECTIVES
In working with families to achieve the goal of improving their abilities to manage family conflict in
a safe,constructive manner,the FT worker strives to accomplish the objective of resolving conflicts
between the parents,the children,and the parents and children so that no maltreatment of the children
occurs,no domestic violence occurs,no children run away from home,and no children commit status
or legal offenses. Sucrces in meeting this goal will be measured by family,caseworker,and therapist
reports that the objectives were met. The family will also be asked to report on their subjective
improvements in this area.
To meet the goal of improving overall parental competency,the level of attainment of objectives of
increasing the parents'abilities to develop and maintain sound,caring,effective relationships with each
other and with their children is assessed.An additional IFT objective is to enhance the abilities of the
parents to provide as well as possible for their family's care,nutrition,hygiene,discipline,protection,
education, and supervision. Again, the parents and children will be polled as to their subjective
opinions about the improvements they have made as will the therapist and caseworker.
The third service goal of the project is to improve household management competency. The objective
here is to enhance the capacity of the parents to provide and to teach the children to provide safe
household environment through competently managing the home to include cleaning,repairing, and
maintaining the home,budgeting, and purchasing. Families who do not have a working financial
budget develop and adhere to one with the aid of the therapist. The family,therapist,and caseworker
document the improvements made in this area.
The fourth service goal of IFT services is to improve the family's abilities,individually and collectively,
to find and use appropriate resources. Treatment and case management services assist the family to
learn more effective means to obtain needed help from other sources in the community and from local,
state, and federal governments. The families will report, and their caseworker and therapist will
confirm, gains in this goal and objective.
vL WORKLOAD STANDARDS
A worker in the Family Preservation Team(FYT)of N.R.B.H. will have a caseload of not more than
eight 1FT families at any given time. The actual caseload size is dependent on the nature of her or his
overall caseload. He or she provides an avenge minimum of three hours of direct family preservation
services per IFT family per week. This does not include the time required to be spent receiving clinical
supervision or in-service training nor the travel time to reach the families served Also,not included
in the weekly three hours average is the up to one hour per week of case management services
required to assist the family to achieve its goals and objectives. The equivalent of two and one-half
full time employees of the FPT will provide IFT services to client families at any given time provided
sufficient W.C.D.S.S. referrals are received. Additional staff will be employed to meet increased
demand for IFT services should it arise.
Direct supervision of the TT project occurs within the larger FPT. This team, as designed and as
presently proposed in this document and others,comprises up to seven individuals:six mental health
workers and one administrative supervisor. The proposed ratio of mental health workers to
administrative supervisors will never exceed six to one. The supervisor,Patricia Orleans,LCSW,who
also is the director of the Children and Family Services Program (CFSP), reports directly to the
N.RB.H. Executive Director, Dale F. Peterson, MSW, MHO. The supervisor provides clinical
oversight and administration directly to the project as well as clinical supervision to all newly employed
members of the team for at least the first six months of their employment after which an employee
may be permitted to choose a clinical supervisor from among the other qualified staff of N.RB.H.
Ms. Orleans is clinically supervised by Larry Pottorff,LCSW. Also in the clinical and administrative
chains of command is N.RB.H.'s Medical Director, Ted Sills, MD. A board certified child
psychiatrist,Russ Johnson,MD,and two board certified general psychiatrists,Enrique Alvarez,MD
and James Medelman,MD,are available to consult with the FPT staff and to psychiatrically evaluate
family members in need of such services.
The present treatment staff members fully assigned to the FPT are Josephine Lucero,MA LPC,Rich
Hedlund,MA LPC,Jamie Moe-Hartman,MA, and Greg Creed,BA(to receive MA in May, 1999).
Their efforts are a+ngnwnted by other staff,including Meg Baker,LCSW, Greg Bjork,MA LPC,Lin
Moersen,MSW, Leonor Willis, MA LPC,and Ave Maria Williams, MSW, from N.RB.H. when
necessary to carry out the service plan of a client family.
VII. STAFF QUALIFICATIONS
All present staff members of N.R.B.H.'s FPT exceed,and all future staff members will meet or exceed
the qualifications necessary to be a Caseworker III within the state social services system. Caseworker
Ills must have at least obtained a bachelor's degree in one of the human behavioral science fields and
have not less than two years of full time professional social casework experience or its equivalent after
having completed the baccalaureate degree. All present members of the team have master's degrees
in the human services fields from accredited universities and have at least two years experience
working with children and families.
Due to the use of the team approach,the members of the team,while specializing in the provision of
family preservation services,carry a diverse caseload in that each may provide a combination of the
four different types of family preservation services offered by N.R.B.H.. The equivalent of, as a
minimum,at least two and one-half fill time employee will be available to provide IFT services to
client families at any given time. Psychiatric and psychological evaluations will be performed by
individuals licensed to practice their individual specialties in Colorado.
Each member of the FPT will be knowledgeable in family and individual dynamics and in the
treatment of a wide variety of family problems as demonstrated by specialized training,workshops,
and experience in working with families. Each FPT member working with a family within the IFT
project will receive a monthly minimum of four hours of clinical supervision from an N.R.B.H. staff
member with advanced skills in intensive family therapy. This supervision will address such things as
diagnostics,treatment planning,use of the self in the treatment relationship,strategies of intervention,
dealing with resistance, and obstacles to the treatment process. Clinical supervisors will also be
involved in regular training to keep current in state-of-the-art counseling modalities and findings.
RFP-FYC-99008 Attached A
VIII. COMPUTATION OF DIRECT SERVICE RATE
This form is to be used to provide detailed explanation of the hourly rate your
organization will charge the Core Services Program for the services offered in
this Request for Proposal. This rate may only be used to bill the Weld County
Department of Social Services for direct, face-to-face services provided to
clients referred for these services by the Department. Requests for payment based
on units of service such as telephone calls, no shows, travel time, mileage
reimbursement, preparation, documentation, and other costs not involving direct
face-to-face services will not be honored. Likewise, billings must be for hours
of direct service to the client, regardless of the number of staff involved in
providing those services. Therefore, it is imperative that this rate be
sufficient to cover all costs associated with this client, regardless of the
number of staff involved in providing these services.
(Explanations for these Lines are Provided on the Following Page)
Total Hours of Direct Service per Client 77.25 Hours (A]
Total Clients to be Served 35 Clients [B]
Total Hours of Direct Service for Year 2.704 Hours [C]
(Line [A] Multiplied by Line [B]
Cost per Hour of Direct Services $ 35.70 Per Hour [D]
Total Direct Service Costs $ 96,532.80 [E]
(Line [C] Multiplied by Line [DI )
Administration Costs Allocable to Program $ 37,423.36 [F]
Overhead Costs Allocable to Program $ 50,645.92 [C]
Total Cost, Direct and Allocated, of Program$ 184,602.08 [H]
Line [E] Plus Line [F] Plus Line [G] )
Anticipated Profits Contributed by this Program $ 0 [I]
Total Costs and Profits to be Covered 184,602.08
by this Program(Line [H] Plus Line [I] ) $ [J]
Total Hours of Direct Service for Year 2,704 [K]
(Must Equal Line [C] ) - ---
Rate per Hour of Direct, Face-to-Face Service
to be Charged to Weld County Department of $ 68.27 [LI
Social Services
Day Treatment Programs Only:
Direct Service House Per Client Per Month [M]
Monthly Direct Service Rate $ [N]
Page 34 of 35
VIM RATE COMPUTATION:BUDGET DESCRIPTION
Personnel costs are predominant in this budget The above figures represent the equivalent of 2.50
filler clinical staff of North Range Behavioral Health(NRBH)working within the 1FT to deliver
those clinical,case management,support,and supervisory services required by individual service plans
and the requirements set forth in this proposal. Direct services personnel costs equal$35.70 per direct
service hour,or 52%of the total of$68.27. Supervisory costs are S9.99,or 15%of the total direct
time cost. The clerical support services costs are$3.85,or 6%of the total. The agency overhead of
$18.73 amounts to 27%of the total cost per hour. Psychiatric and psychological services are available
at an hourly rate of$92.56 for those clients needing them and will be billed separately from other
clinical services.
All PAC funds will be accounted for separately within the overall budget of NRBH. Each project is
regarded as a distinct cost center. NRBH,including its use of PAC funds, is independently audited
annually.
IX. PROGRAM CAPACITY BY MONTH
The IFT is designed to function with a minimum staff contingent of 2.50FTE, serving an average of
35 children and their families at any given time throughout the upcoming fiscal year. N.R.B.H. will
be pleased to accept as many additional families as are determined to need this level and type of care.
We will develop sufficient staffing patterns to accommodate any and all families needing the EFT
service.
ACORbr Ian.nuscoo TE QF I I U �C 0DAIIIIMMDAnn
3/0
PRODUGFR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Flood & Peterson Ins. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P. O. HOX 578 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
4687 W. 18th Street COMPANIES AFFORDING COVERAGE
Greeley, CO 80632
COMPANY
ACNA Insurance
INSURED
North Range Behavioral Health COMPANY
1306 llth Avenue
Greeley, CO 80631 COI'P
ANY
COMPANY
I D
......................................... ... .
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE PIXICY EXPIRATION UMITS
DATE BAWDDN Nd Y) DATE(MMYY)
A GENERALLIABIUTY S182327225 01/01/99 01/01/00 GENERAL AGGREGATE s3, 000, 000
X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG s3, 000, 000
(CLAIMS MADE X OCCUR PERSONAL SADV INJURY S1, 000, 000
OWNER'S B CONTRACTOR'S PROT EACH OCCURRENCE S1, 000, 000
FIRE DAMAGE(Any one fire) s50, 000
MEDEXP(Any one Person) S5, 000
A AUT�OBLEUABILrTY S182327225 01/01/99 01/01/00 COMBINED SINGLE LIMIT $l, 000, 000
ALL OWNED AUTOS
BODILY INJURY S
X SCHEDULED AUTOS (Pe,Person)
X HIRED AUTOS
BODILY INJURY S
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE
GARAGE UABIUTY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY
EACH ACCIDENT S
_ --_ AGGREGATE S
— --
A EXCESSUABIUTY 8182327225 01/01/99 01/01/00 EACH OCCURRENCE 32 , 000, 000
X UMBRELLA FORM AGGREGATE s2, 000, 000
OTHER THAN UMBRELLA FORM S
— t
WORKERS COMPENSATOR AND STATUTORY LIMITS
EMPLOYERS'LIABILITY _. .. __
EACH ACCIDENT S
THE PROPRIETOR/ INCL DISEASE-POLICY LIMIT S
PARTNERS/EXECUTNE - -- -
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE S
A OTHER Prof . Liab. S182327225 01/01/99 01/01/00 $1, 000, 000 ea. pers .
Claims Made $3 , 000 , 000 total limi
DESCRIPTION OF OPERATIONSA.00ATIONSNEHICLES/SPECIAL ITEMS
Retro date 7/1/86
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
Weld County Placement EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Alternatives Committee 1() _DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
c/o Weld County, Department of BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABIUTY
Social Security OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
800 8th Avenue AUTORIED REPRESENTATIVE
Greeley, CO 80631 F/DodV- eleAsonInSUAance , -VW ACORD264l )1 Of 1 #5100083/M10'0081 FPM • 0ACORPCORPORATIONI993
-
[ COLORADO CLIENT ASSESSMENT RECORD
NAME: ■■ GAF SCORE
I I I 'AGENCY 1-3I I I PROGRAM44 (1))American "IndiWAtaslan Native §
11 1 1 1 1 1 1 1 ICUENT ID 414 (2)Asian/Pacific Islander
(3)Black
REFERRING AGY,. (4)Hispanic
CLIENT 1em (5)White(Non-Hispanic)
_ (6)Multi-Racial
I I I I I I I I I 'MEDICND ID 24-32 HISPANIC ORIGIN 75 '' :E:
ADMISSION DATE uw (1)Not of Hispanic Origin
MONTH DAY YEAR (2)Mndcan/Medcan-American
(3)Puerto Rican
ACTION TYPE (Manual Input Only) 41.42 (4)Cuban
_ (5)Other Hispanic
01=Admission 11=Correction to Admission MARITAL STATUS x
02=Activate 12=Correction to Activation
03=Update 13=Correction to Update (1)Never Married (4)Widowed
04=Iracdvate 14=Correclbn to Inactivation (2)Married (5)Divorced
O5=DIsdarge 15=Correction to Discharge _ (3)Married Separated(Legal or Marital Discord)
06=Evaluatlon Only PLACE OF RESIDENCE n
MEDS ONLY CLIENT 43 (i)Correctional Fadlity[Jail
(1)Yes (2)No (2)Inpatient
(3)Nursing Home
ADMISSION STATUS as (4)Residential Facility-Mental Health
(1)New Admission (55)Residential Facility-Non- Mental Health
(2)Readmission From This Fiscal Year ( )Boarding Home
(3)Readmission From Prior Fiscal Year (7)Homeless- Sr
(8)HomelessO the-On Street
PERMANENT HANDICAPRMPAIRMENT 4s49 _ (9)Other Independent Living Arrangement
(Code d j,5 Boxes Using 1 Yes 2 No) CURRENT LIVING ARRANGEMENT is
(1)Mental Retardation
(2)Deafness or Severe Hearing Loss (1)Lives With Both Parents
(2)Lives With One Parent
(3)BlIndness or Severe Visual Impairment (3)Lives With Spouse and or Other Relative(s)
(4)Speech Impairment (4)Lives Alone
(5)Non-Ambulatory or Assisted Ambulation _ (5)Lives With Unrelated Person(s)
LEGAL STATUS CURRENT EMPLOYMENT STATUS re I
(1)Employed-Fun Time
(1)Voluntary E Part Time
(2)(2)Court-Directed Voluntary (3)Homemaker-Not Otherwise Employed
(3)Forensic Involuntary (4)Sheltered Employment
(4)72-How Evaluation and Treatment(MH-HOLD) (5)Not in Labor Force
(5)Shod-Term Certified (6)Unemployed For Less Than 3 Months
(6)Long-Term Certified (7)Unemployed For 3 Months or More
(7)Voluntary Hospitalization of Minors ` (8)Armed Forces(Active Military Duly)
(8)Childrers'Code C.R.S.19-1-101
(9)Emerg/nvol.Alcohdfsm/Dng Commitment ANNUAL FAMILY HOUSEHOLD INCOME N n0
Kate REFERRAL SOURCE 5142 — 1---1-1 . I I
PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS agar NUMBER OF PERSONS SUPPORTED BY es
le i➢pOeeMl THIS INCOME(Include Client)
- I 1 1 • I I I l 11 I l (1)1 (client only) (6)6
PRESENTING PROBLEM HAS EXISTED se (2)2 (7)7
(1)1 Year or Longer (2)Less Than 1 Year (4)4 (9)8
(4)4 (9)9 or More
PREVIOUS MENTAL HEALTH SERVICES e442 _ (5)5
(Code ALL Four Boxes thing 1 Yes 2 No) HIGHEST EDUCATION LEVEL-IN YEARS e447
Inpatient Care
_ (LessFirs/ThanFirs/Grade Code as 00)
Other 24-Hour Care
Partial Care DUE TO MENTAL HEALTH REASONS, n
Care CLIENT IS CURRENTLY RECEIVING:
Outpatient (1)S51 (3)Both
I I COUNTY OF RESIDENCE n-a _ (2)SSDI (4)Neither
DATE OF BIRTH i esn FIRST 3 LETTERS OF CLIENTS LAST NAMEa41 I I
—
l,,. '. .;y,DA •, g tt 1 l ZIP CODE n n-w as g
YEA
_ 1 I I I 1 -[ l f l
SEX n Triage Denver Health&Medical Center Only for
(1)Male (2)Female
.... .. ..... _.. _ . SHADED ROPES ARE NOT PROCESSED ON UPDATE
1
l COLORADO CLIENT ASSESSMENT RECORD 2
1
Client I.D. Name_ Admit Date
HISTORY 102-t06 Check ALL that Apply CURRENT PSEV Cheek ALL Problems that Apply
—Via:Sexual Abuse Hist:Suicide Attempt _Hist:Unstable Employm CT AGGRESSIVENESS 1et-197
VS:Physical Abuse Hit:Family Ment-9l
- ct:Neglect _Hiat:Family Sub-Abuse —_!nor Out
_Threatening
Aggressive Hostile Intimidating
SPECIAL PROBLEMS/ISSUES twits Check ALL that Apply -- — -
-] ANTISOCIAL, 196-203
_Leasing Disability CNS Disorder _Language Issues Disrespect Disregards Rules UsesMans OthersLoss/Grie/ Welting/Soiling/Shcinp Cultural/Belief Issues —
Eating Disorder _Fire SeUDestroy Property __Dk°bedicnt —Dishonest
PROBLEM SEVERITY E] J,EGA4 2e4-210
__Legal Problems Probations/Parole _Offenses:Property
RATE the CURRENT P-SEV(PROBLEM SEVERITY} __Charges Pending _Offenses:Substances _Offenses:Persons
for each area in the boxes provided,using the following scale:
None Slight Moderate Severe Extreme C] VIOLENCE/DANGER TO OTHERS 211-217
1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 __Violent _HomicidalIdeation
__Assaultive Homicidal ThreaVMempt
CURRENT P-SEV Check ALL Problems that Apply —_Phys/Sc atal Abuser =Danger to Others O.R$IOO
EMOTIONAL WITHDRAWAL ttr-in El FAMILY ISSUES 215-225
Underac-tive _Passive _Doesn't Verbalize Feelings
_Distan ue t _Subdd _Blunted Med No Family/No Contact Family Legal _Domestic Violence
Out of Home Placement Parenting Unstable Home/Fam
DEPRESSION 12s-12o -- ratSepa ust — —
— ody
Depressed _Lonely _
ess Hopeless pi FAMILY PROBLEMS WITH 226nt
Worthless _Sad _Dejected
Parent _Partner _Relative
__
ANXIETY tat-159 __Sibling _Child
_Anxious _Nervous Panic p] INTERPERSONAL PROBLEMS 232-236
Tense Flashbacks Phobic
_-Fearful Nightmares/Terrors __w/Friend _Establishing Relationships
HYPER AFFECT 140-146 —_Social Skills —Maintaining Relationships
_Overactive _Pressured Speech _Elevated Mood [] ROLE PERFORMANCE(Work/School} 237-243
Mood Swings Accelerated Speech Mania
— Absenteeism Performance _Behavior
ATTENTION PROBLEMS 147-152 --SuspensiaWrobation Termination _
[ Limited Employability
_Agitated _Distractible Mention Span ] SUBSTANCE ABUSE 2M-249
Restless Impulsive Concentration
— Problem w Alcohol DependenVAddicted In Recovery
SUICIDE/DANGER TO SELF - 154-160 --Problem w Drugs —_
[ Interferes with Responsibilities
_Suicide Ideation _Self-Injury/Mutilation ] MEDICALIPHYSICAL 250-254
Suicide Plan Reckless Self-Endangerment
Suicide AttemptDanger to Self (VRS's rly::'. __Acute Illness _Medical Care Needed Physical Handicap
Chronic Illness InjuryByAbuse/Assault Permanent Disability
THOUGHT PROCESSES lsatce
[] SECURITY/MANAGEMENT ISSUES 257-255
Bane Suspicious _Repeated Thought
Delusions _Paranoid _Obsessive Seclus�me Out Walkaway/Escape _Behavior Managemt
Hallucinations __Close Supervision _Security Suicide Watch
Medication Compliance Inadequate Mull Supervision
COGNITIVE PROBLEMS 169-175 -- —
Confused Loose Associations Lacks Self Awareness _OVERALL DEGREE OF PROBLEM SEVERITY lac
—Disoriented DisorganizedImpai sor red Judgement Check ONE Response
SELF-CARE/BASIC NEEDS 17e-in None Slight Moderate Severe Extreme
Hygiene Doesn'tManage Money Doesn't Provide Food 1 2 3 4 5 6 7 8 9
Self Care Problems Doesn't Use Resources Doesn't Provide Housing
_Gravely Disabled .empy:1(p; UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
_CHANGE IN OVERALL PROBLEM SEVERITY 267
RESISTIVENESS 164/so Check ONE Response
Resistive _Evasive Wary Much Much
-Uncooperative Guarded Denies Problems Better Better No Change Worse Worse
1 2 3 1 5 6 7 8 9
f COLORADO CLIENT ASSESSMENT RECORD 3
Client I.D. Name Admit Date
STRENGTHS/RESOURCES I� LEVEL-OF-FUNCTIONING (LOF)
CUR
RENT d}mothsSTRENGTHSIRESOUmothshat I Cheek ONE Response for Each LOF Area
ECONOMIC RESOURCES 2811-274 SOCIETAL/ROLE FUNCTIONING 306
_MedialdiMedlare _Employment Transportation Very High Moder High Average Moder Low Very Low
_Other
Medical Your _Horsing Function Function Function Function Function
_Other Public Assist _Fkuncial _ _
EDUCATION I SKILL RESOURCES 27s273 z a s a e —y
LanguageSMIbINTERPERSONAL FUNCTIONING b5
Language _kdapersarral Skills _Intell'perlce Very High Moder High Average Moder Low Very Low
_Edrsalia _Job Skills Function Function Function Function Function
PERSON RESOURCES 2eo-ter
_Parenl(s) Partner Professional Caregiver 1 2 3 4 5 6 7 8 9
Sibling(s) Chdd(ren) _Other Supportive Relationship DAILY LIVING/PERSONAL CARE FUNCTIONING aos
_Relative(s) _Frbnd(s) Very High Moder High Average Moder Low Very Low
PERSONAL STRENGTHS 2ee301 Function Function Function Function Function
_Likeableness _Emotional Stability _Adaptability 1 2 3 4 5 6 7 8 g
_Appearance _Health _Thought Clarlty PHYSICAL FUNCTIONING 3o7
—Judgement
_Hopefulness _Resourcefulness
Judgement _Responsibility Tolerance Very High Moder High' Average Moder Low Very Low
Empathy Function Function Function Function Function
1 2 3 1 5 a 7 8 9
COGNITIVE/INTELLECTUAL,FUNCTIONING 308
Very High Moder High Average Moder Low Very Low
Function Function Function Function Function
1 2 3 4 5 6 7 8 9
CURRENT OVERALL STRENGTHS/RESOURCES 302 OVERALL LEVEL OF FUNCTIONING Check ONE Response 309
Check ONE Response Very High Moder High Average Moder Low Very Low
Very High High Moderate Some Very Low Function Function Function Function Function
1 2 3 4 5 6 7 8 9 1 2 3 / 5 6 7 8 9
UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY UPDATE.ACTIVATE.INACTIVATE&DISCHARGE ONLY
CHANGE IN OVERALL STRENGTHS/RESOURCES 303 CHANGE IN LEVEL OF FUNCTIONING Check ONE Response 310
Check ONE Response Much Much
Much Much Better Better No Change Worse Worse
Better Better No Change Worse Worse _ _
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
I I III I I STAFF ID 311-319 STAFF SIGNATURE
IlDISCIPLINE: 1=none 2=mh worker 3=nursing 4--social won( 5=psychology 6=psychiatry 7=other 320
TJDEGREE' 1=none 2=associate 3=bachelors 4-masters 5=PhD/PsyD/EdD 6=MD 7=ather 321
COMPLETE THIS BOX ONLY FOR COMPLETE THIS BOX ONLY AT DISCHARGE
UPDATE,ACTIVATE AND INACTIVATE STATUS C I=E]
DATE FORM COMPLETED
MONTH DAY YEAR 336337
C I I III ] !AST CONTACT DATE
MONTH DAY YEAR 338-345
EFFECTIVE DATE 322-329 C I DISCHARGE DATE
MONTH DAY YEAR MONTH �� YEAR 346-353
El TYPE OF TERMINATION- 354
SPECIAL STUDIES laDischarged'Transrerred 54From Inactive
2-TX Completed/No Referral 64Patieo/Client Died
�7 3=TX Completed/Follow-up 7-PatienVClient Terminated
4Evaluation Only
367416 C I TERMINATION REFERRAL; 333356
NOTE:Use 61 'Self if no Referral
FAMILY PRESERVATION PROGRAM ADMISSION EVALUATION FORM (7/97)
Client Name _ Client Id4
Diagnosis: Primary Secondary
Date of Birth School Grade City
Admit Date Center
Medicaid _ Yes _ No (Check One) Sex _ Ethnicity
Who had custody of youth at time of referral to FPP
Where was youth residing at time of admission to FPP (Be specific)
Date of initial referral for FPP services
Date of first contact by FPP therapist
FPP Therapist
Previous mental health services (explain)
Special Behaviors or Circumstances/Reasons for referral
PAST PRESENT
Yes No Yes No
Suicidal
Violence toward others
Runaway Behavior _
Social Isolation
Legal Charges
Domestic Violence
On Probation
Victim Physical Abuse
Victim Sexual Abuse
Alcohol Use
Use of Inhalants
Other Drug Use
Learning Disabilities
Special Education
Bed Wetting
Enoorpresis
Others (specify
OAF SCORE AT ADMISSION TO FPP
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNCTIONING SCORES AT ADMISSION TO FAMILY PRESERVATION PROGRAM
(RATE ALL SIX AREAS)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
SOCIETAL FUNCTIONING
INTERPERSONAL FUNCTIONING
DAILY LIVING PERSONAL CARE
PHYSICAL FUNCTIONING
COGNITIVE INTELLECTUAL
OVERALL LEVEL OF FUNCTIONING
FAMILY PRESERVATION PROGRAM TERMINATION EVALUATION FORM (7/97)
Client Name _ Client Id#
Discharge date from FPP
List all different types of FPP services used _
Discharge Diagnoses: Primary Secondary
Who has custody of child at time of termination from FPP?
Where was child living immediately after termination fran FPP?
Who will follow youth after discharge?
Special Behaviors or Circumstances
PRESENT
Yes No
Suicidal
Violence toward others
Runaway Behavior
Social Isolation
Legal Charges
On Probation
Victim Physical Abuse _
Victim Sexual Abuse
Alcohol Use
Use of Inhalants
Other drug use
Learning Disabilities _
Special Education
Bed Wetting
Enoorpresis _
Domestic Violence
Others (specify) _
GAF SCORE AT DISCHARGE
OVERALL PROBLEM SEVERITY SCORE
LEVEL OF FUNCTIONING SCORES AT DISCHARGE FROM FAMILY PRESERVATION PROGRAM
(RATE ALL SIX AREAS)
High Moder. Aver. Moder. Very
Func. High Low Low
1 2 3 4 5 6 7 8 9
SOCIETAL FUNCTIONING
INTERPERSONAL FUNCTIONING
DAILY LIVING PERSONAL CARE
PHYSICAL FUNCTIONING
COGNITIVE INTELLECTUAL
OVERALL LEVEL OF FUNCTIONING _
l r.' .�: rP
North Range
Behavioral Health
May 19, 1999
Judy A. Griego, Director
Weld County Department of Social Services
P.O. Box A
Greeley, CO 80632
Re: RFP Recommendations and Conditions
Dear Ms. Griego:
The purpose of this letter is to respond to the recommendations and conditions specified in
your letter of May 14, 1999.
Intensive Family Therapy (RFP 99008)
1. Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (b)
Payment will be denied to IFT providers for any charges submitted foe therapy 45 minutes
or less unless cleared by explanation and approved by the program area supervisor.
NRBH Response: (a) IFT providers will receive further training and closer supervision, in
order to insure that quarterly reports are made in a timely manner. (b) This condition is
understood and it will be communicated to the appropriate IFT and billing personnel.
Option B (RFP 99010)
2. Recommendation: The program should be goal oriented. This program does receive
more than eight referrals a year.
NRBH Response: Close supervision will take place in order to insure that the program
remains oriented toward fulfilling the goals expressed in the proposal. The Option B
Program will be prepared to accept significantly more than eight referrals, as needed.
13116 11ii Aorrri rr- /Gi,.I .1'U F0631 /(970)3n4-3;86/F.0 1970)453.3906
Option B (RFP 99010) continued
2. Condition: Submit timely quarterly reports to caseworkers and offer more flexibility
with time frames for clients.
NRBH Response: Option B providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner. Additionally, closer
supervision and the further addition of potential providers will allow more time frame
flexibility.
Sex Abuse Treament (RFP 99007)
3. Recommendation: Submit timely quarterly reports to caseworkers.
NRBH Response: Treatment providers will receive further training and closer supervision,
in order to insure that quarterly reports are made in a timely manner.
Day Treatment (RFP 99006)
4. Recommendation: The caseworker shall be involved in the assessment process.
NRBH Response: The is little doubt that the involvement of the caseworker is a necessity
in the assessment process. Closer supervision will occur to insure that greater effects are
made to contact and communicate with caseworkers during tha assessment process.
If you have any further concerns or questions please let us know and we will address them
as quickly and effectively as possible.
Sincerely,
orfx
Ch s A. Howard, h.D.
Director of Children and Family Services
/t.�elii.kx
Dale F. Peterson, M.S.W., M.H.A, Director
North Range Behavioral Health
, • 0
DEPARTMENT OF SOCIAL SERVICES
PO BOX A
' GREELEY, CO 80632
Administration and Public Assistance(970)352-1551
C Child Support(970)352-69331
Protective and Youth Services(970)352-1923
COLORADO May 14, 1999
Mr. Dale Peterson, Director
North Range Behavioral Health, Inc.
1306 11 Avenue
Greeley, CO 80361
Dear Mr. Peterson:
Re: RFP 99008 (IFT) Intensive Family Therapy
RFP 99010 Option B
RFP 99007 Sex Abuse Treatment
RFP 99006 Day Treatment
Dear Mr. Peterson:
The purpose of this letter is to outline the results of the RFP Bid process for PY1999-2000 and to
request written information or confirmation from you by May 20, 1999.
A. Results of the RFP Bid Process for PY1999-2000
On April 7, 1999, the Families, Youth and Children (FYC) Commission approved the
RFP(s) listed above for inclusion on our vendor list. The FYC Commission attached the
following recommendations and/or conditions regarding your RFP bid(s).
1. RFP 99008, Intensive Family Therapy:
Conditions: (a) Quarterly reports be made in a timely manner to caseworkers; (b)
Payment will be denied to Intensive Family Therapy providers for any charges
submitted for therapy 45 minutes or less unless cleared by explanation and
approved by the program area supervisor.
2. RFP 99010, Option B:
Recommendation: The program should be goal oriented. This program does
receive more than eight referrals per program year.
Condition: Submit timely quarterly reports to caseworkers and offer more
flexibility with time frames for clients.
Page 2
North Range Behavioral Health/May 14, 1999
3. RFP 99007, Sex Abuse Treatment:
Recommendation: Submit timely quarterly reports to caseworkers.
4. RFP 99006, Day Treatment:
Recommendation: The caseworker shall be involved in the assessment process.
B. Required Response by RFP Bidders Concerning FYC Commission
Recommendations and Conditions.
The Weld County Department of Social Services is requesting your written response to
the FYC Commission's recommendations and conditions. Please respond in writing to
David Aldridge, Weld County Department of Social Services, P.O. Box A, Greeley, CO,
80632, by May 20, 1999, close of business, as follows:
1. FYC Commission Recommendations:
You are requested to review the FYC Commission recommendations and to:.
a. accept the recommendation(s) as written by the FYC Commission; or
b. request alternatives to the FYC Commission's recommendation(s); or
c. not accept the recommendation(s) of the FYC Commission.
Please provide in writing how you will incorporate the recommendation(s) into your
bid. If you do not accept the recommendation, please provide written reasons why.
All approved recommendations under the NOFAA will be monitored and evaluated
by the FYC Commission.
2. FYC Commission Conditions:
All conditions will be incorporated as part of your RFP Bid and Notification of
Financial Assistance Award (NOFAA). If you do not accept the condition(s), you
will not be authorized as a vendor unless your mitigating circumstances are accepted
by the FYC Commission and the Weld County Department of Social Services. If you
do not accept the condition, you must provide in writing reasons why. A meeting will
be arranged to discuss your response. Your response to the above conditions will be
incorporated in the RFP Bid and Notification of Financial Assistance Award.
Page 3
North Range Behavioral Health/May 14, 1999
If you wish to arrange a meeting to discuss the above conditions and/or recommendations, please
do so through Elaine Furister, 352.1551, extension 6295, and one will be arranged prior to May
20, 1999.
Sincerely, a
J 1, A. I riego, D recto
d County Department of Social Services
cc: Mike Hoover, Chair, FYC Commission
David Aldridge, Social Service Manager II
JG:ef
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