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Home My WebLink About20240195.tiffRESOLUTION RE: APPROVE PROFESSIONAL SERVICE AGREEMENT FOR VARIOUS CORE AND NON -CORE CHILD WELFARE SERVICES AND AUTHORIZE CHAIR TO SIGN - CROSSROADSX COUNSELING PROFESSIONAL, LLC WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Professional Service Agreement for Various Core and Non -Core Child Welfare Services 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 Human Services, and Crossroadsx Counseling Professional, LLC, commencing January 1, 2024, and ending May 31, 2024, with further terms and conditions being as stated in said agreement, and WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Professional Service Agreement for Various Core and Non -Core Child Welfare Services 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 Human Services, and Crossroadsx Counseling Professional, LLC, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 24th day of January, A.D., 2024, nunc pro tunc January 1, 2024. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, ATTEST: Cl ki.4 Weld County Clerk to the Board BY:kut f .1/00n !x(11 C C APP Deputy Clerk to the Board County Attorney Date of signature: Z(, /z4 O,. _ Key . Ross, Char ,,j,1•12X erry L. B , , Pro-Tem Mike Freeman James c� H SD 0.2 a3 f 4 2024-0195 HR0096 Ccr\-vacs- ti* 1ct BOARD OF COUNTY COMMISSIONERS PASS -AROUND REVIEW PASS -AROUND TITLE: Professional Service Agreement with Crossroadsx Counseling Professional, LLC DEPARTMENT: Human Services DATE: January 9, 2024 PERSON REQUESTING: Jamie Ulrich, Director, Human Services Brief description of the problem/issue: The Department is requesting to enter into a Professional Service Agreement (PSA) with Crossroadsx Counseling Professional, LLC for Sexual Abuse Treatment Services. The Child Welfare Division puts forth a Request for Proposal yearly to contract with Providers who provide various needed services. Crossroadsx Counseling Professional, LLC has submitted the correct paperwork and is requesting to provide needed services under Bid B2300040. What options exist for the Board? Approval of the PSA with Crossroadsx Counseling Professional, LLC. Deny approval of the PSA with Crossroadsx Counseling Professional, LLC. Consequences: New Core/Non-Core Services Provider will not be approved. Impacts: Provider will not provide needed Services to Department of Human Services clients. Costs (Current Fiscal Year / Ongoing or Subsequent Fiscal Years): Funded through: Core/Non-Core Child Welfare funding. Term: January 1, 2024 through May 31, 2024. Fees for Services: Program Unit Area Rate Type Service Name Sexual Abuse Treatment $110.00 , Hour $110.00 $ 50.00 Hour Each Offense Specific Treatment - In -Of lceNideo Offense Specific Treatment: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing Offense Specific Treatment No -Show Pass -Around Memorandum January 9, 2024 - CMS ID 7729 2024-0195 /Z4 41,eooctcD Recommendation: • Approvai of the Professional Service Agreement and authorize the Chair to sign. Support Recommendation Schedule Place on BOCC Agenda Work Session Other/Comments: Perry L. Buck, Prc-Tem Mike Freeman, Chair Scott K. James Kevin D. Ross Lori Seine flo Pass -Around Memc'andum January 9, 2024 - CMS ID 7729 act PROFESSIONAL SERVICE AGREEMENT BETWEEN WELD COUNTY AND CROSSROADSX COUNSELING PROFESS ZONAL, LLC THIS AGREEMENT is made and entered into this Z'4 ay of ,ki B 204, by and between the Board of Weld County Commissioners, on behalf of the Weld County epartment of Human Services, hereinafter referred to as "County," and Crossroadsx Counseling Professional, LLC, hereinafter referred to as "Contractor". WHEREAS, County desires to retain Contractor to perform services as required by County and set forth in the attached Exhibits; and WHEREAS, Contractor is willing and has the specific ability, qualifications, and time to perform the required services according to the terms of this Agreement; and WHEREAS, Contractor is authorized to do business in the State of Colorado and has the time, skill, expertise, and experience necessary to provide the services as set forth below; and WHEREAS, the Colorado Department of Human Services has provided Core and Non - Core or other funding to the Department for Sexual Abuse Treatment Services. NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties hereto agree as follows: 1. Introduction. The terms of this Agreement are contained in the terms recited in this document and in the attached Exhibits, each of which forms an integral part of this Agreement and are incorporated herein. The parties each acknowledge and agree that this Agreement, including the attached Exhibits, define the performance obligations of Contractor and Contractor's willingness and ability to meet those requirements (the "Work"). If a conflict occurs between this Agreement and any Exhibit or other attached document, the terms of this Agreement shall control, and the remaining order of precedence shall be based upon order of attachment. Exhibit A consists of the Scope of Services. Exhibit B consist of the Rate Schedule. Exhibit C consists of the County's Request for Proposal (RFP) as set forth in Bid Package No. 132300040 which is incorporated into this agreement by reference and will be provided upon request to the Department. Exhibit D consists of Contractor's Response to County's Request. 2. Service or Work. Contractor agrees to diligently provide all services, labor, personnel and materials necessary to perform and complete the Work described in the attached Exhibits. Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibits A, Scope of Services, and Exhibit D, Contractor's Response to Request for Proposal. Contractor shall further be responsible for the timely completion and acknowledges that a failure to comply vh the standards and requirements of Work within the time limits prescribed by County may result in County's decision to withhold payment or to terminate this Agreement. 3. Term. The term of this Agreement shall be from January I. 2024, through May 31, 204, unless sooner terminated as provided herein. Both of the parties to this Agreement understand and agree that the laws of the State of Colorado prohibit County from entering into Agreements which bind County for periods longer than one year. This Agreement maybe renewed for 2 (two) additional one-year terms upon mutual written agreement of the Parties. 4. Termination; Breach; Cure. County may terminate this Agreement for its own conveniern,e upon thirty (30) days written notice to Contractor. Either Party may immediately terminate this Agreement upon material breach of the other party, however the breaching party shall have fifteen (15) days after receiving such notice to cure such breach. If this Agreement is terminated by County,. Contractor shall be compensated for, and such compensation shall be limited to, (1) the sum of the amounts contained in invoices which it has submitted and which have been approved by the County; (2) the reasonable value to County of the services which Contractor provided prior to the date of the termination notice, but which had not yet been approved for payment; and (3) the cost of any work which the County approves in writing which it determines is needed to accomplish an orderly termination of the work. County shall be entitled to the use of all material generated pursuant to this Agreement upon termination. Upon termination of this Agreement by County, Contractor shall have no clam of any kind whatsoever against the County by reason of such termination or by reason of any act incidental thereto, except for compensation for work satisfactorily performed and/or materials described herein properly delivered. 5. Extension or Amendment. Any amendments or modifications to this agreement shall be in writing signed by both parties. No additional services or work performed by Contractor shall be the basis for additional compensation unless and until Contractor has obtained written authorization and acknowledgement by County for such additional services. Accordingly, no claim that the County has been unjustly enriched by any additional services, whether or not there is in fact any such unjust enrichment, shall be the basis of any increase in the compensation payable hereunder. In the event that written authorization and acknowledgment by the County for such additional services is not timely executed and issued in strict accordance with this Agreement, Contractor's rights with respect to such additional services shall be deemed waived and such failure shall result in non-payment for such additional services or work performed. Any claims by the Contractor for adjustment hereunder must be made in writing prior to performance of any work covered in the anticipated Amendment, unless approved and documented otherwise by the County Representative. Any change in work made without such prior Amendment shall be deemed covered in the compensation and time provisions of this Agreement, unless approved and documented otherwise by the County Representative. 6. Compensation. County agrees to pay Contractor through an invoice process during the course of dais Agreement in accordance with the Rate Schedule as described as Exhibit B. Contractor agrees to submit invoices which detail the work completed by Contractor. The County will review each invoiae and if it agrees Contractor has completed the invoiced items to the County's satisfaction, it will remit payment to the Contractor. No payment in excess of that set forth in the Exhibits will be made by County unless an Amendment authorizing such additional payment has been specifically approved by Weld County as required pursuant to the Weld County Code. If, at any time during the 2 term or after termination or expiration of this Agreement, County reasonably determines that any payment made by County to Contractor was improper because the service for which payment was made did not perform as set forth in this Agreement, then upon written notice of such determination and request for reimbursement from County, Contractor shall forthwith return such payment(s) to County. Upon termination or expiration of this Agreement, unexpended funds advanced by County, if any, shall forthwith be returned to County. County will not withhold any taxes from monies paid to the Contractor hereunder and Contractor agrees to be solely responsible for the accurate reporting and payment of any taxes related to payments made pursuant to the terms of this Agreement. Unless expressly enumerated in the attached Exhibits, Contractor shall not be entitled to be paid for any other expenses (e.g. mileage). Notwithstanding anything to the contrary contained in this Agreement, County shall have no obligations under this Agreement after, nor shall any payments be made to Contractor in respect of any period after December 31 of any year, without an appropriation therefore by County in accordance with a budget adopted by the Board of County Commissioners in compliance with Article 25, Title 30 of the Colorado Revised Statutes, the Local Government Budget Law (C.R.S. 29-1-101 et. seq.) and the TABOR Amendment (Colorado Constitution, Article X, Sec. 20). 7. Independent Contractor. Contractor agrees that it is an independent contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits (including unemployment insurance or workers' compensation benefits) from County as a result of the execution of this Agreement. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. 8. Subcontractors. Contractor acknowledges that County has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of the Work without County's prior written consent, which may be withheld in County's sole discretion. County shall have the right in its reasonable discretion to approve all personnel assigned to the Work during the performance of this Agreement and no personnel to whom County has an objection, in its reasonable discretion, shall be assigned to the Work. Contractor shall require each subcontractor, as approved by County and to the extent of the Work to be performed by the subcontractor, to be bound to Contractor by the terms of this Agreement, and to assume toward Contractor all the obligations and responsibilities which Contractor, by this Agreement, assumes toward County. County shall have the right (but not the obligation) to enforce the provisions of this Agreement against any subcontractor hired by Contractor and Contractor shall cooperate in such process. The Contractor shall be responsible for the acts and omissions of its agents, employees and subcontractors. 9. Ownership. All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of County. In addition, 3 all reports, documents, data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the County. Contractor shall not make use of suca material for purposes other than in connection with this Agreement without prior written approval cf County. 10. Cmfidentiality. Confidential information of the Contractor should be transmitted separately -from non -confidential information, clearly denoting in red on the relevant document at the top the word, "CONFIDENTIAL." However, Contractor is advised that as a public entity, Weld County mast comply with the provisions of the Colorado Open Records Act (CORA), C.R.S. 24-72- 201, et sec.., with regard to public records, and cannot guarantee the confidentiality of all documents. Contractor agrees to keep confidential all of County's confidential information. Contractor agrees not to sell; assign, distribute, or disclose any such confidential information to any other person or entity without seeking written permission from the County. Contractor agrees to advise its employees, agents, and consultants, of the confidential and proprietary nature of this confidential information and of the restrictions imposed by this Agreement. 11. Warranty. Contractor warrants that the Work performed under this Agreement will be performed in a manner consistent with the standards governing such services and the provisions of this Agreement. Contractor further represents and warrants that all Work shall be performed by qualified personnel in a professional manner, consistent with industry standards, and that all services will conform to applicable specifications. 12. Aeaeptance of Services Not a Waiver. Upon completion of the Work, Contractor shall submit to County originals of all test results, reports, etc., generated during completion of this work. Acceptancm by County of reports and incidental material(s) furnished under this Agreement shall not in any way relieve Contractor of responsibility for the quality and accuracy of the project. In no event shall any action by County hereunder constitute or be construed to be a waiver by County of any breach of his Agreement or default which may then exist on the part of Contractor, and County's action or inaction when any such breach or default exists shall not impair or prejudice any right or remedy available to County with respect to such breach or default. No assent expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed ortaken to be a waiver of any other breach. Acceptance by the County of, or payment for, the Work nompleted under this Agreement shall not be construed as a waiver of any of the County's rights under this Agreement or under the law generally. 13. Insurance. Contractor must secure, before the commencement of the Work, the following insurance covering all operations, goods, and services provided pursuant to this Agreement, and shall keep the r.quired insurance coverage in force at all times during the term of the Agreement, or any extension hereof, and during any warranty period. For all coverages, Contractor's insurer shall waive subrogatior rights against County. a. Types of Insurance. 4 Workers' Compensation / Employer's Liability Insurance as required by state statute, covering all of the Contractor's employees acting within the course and scope of their employment. The policy shall contain a waiver of subrogation against the County. This requirement shall not apply when a Contractor or subcontractor is exempt under Colorado Workers' Compensation Act., AND when such Contractor or subcontractor executes the appropriate sole proprietor waiver form. Commercial General Liability Insurance including public liability and property damage, covering all operations required by the Work. Such policy shall include minimum limits as follows: $1,000,000 each occurrence; $1,000,000 general aggregate; $1,000,000 Personal injury; $5,000 Medical payment per person. Automobile Liability Insurance: Contractor shall maintain limits of $1,000,000 for bodily injury per person, $1,000,000 for bodily injury for each accident, and $1,000,000 for property damage applicable to all vehicles operating both on County property and elsewhere, for vehicles owned, hired, and non -owned vehicles used in the performance of this Contract. Professional Liability (Errors and Omissions Liability). The policy shall cover professional misconduct or lack of ordinary skill for those positions defined in the Scope of Services of this contract. Contractor shall maintain limits for all claims covering wrongful acts, errors and/or omissions, including design errors, if applicable, for damage sustained by reason of or in the course of operations under this Contract resulting from professional services. In the event that the professional liability insurance required by this Contract is written on a claims - made basis, Contractor warrants that any retroactive date under the policy shall precede the effective date of this Contract; and that either continuous coverage will be maintained, or an extended discovery period will be exercised for a period of two (2) years beginning at the time work under this Contract is completed. Minimum Limits: $1,000,000 Per Loss; $2,000,000 Aggregate. b. Proof of Insurance. Upon County's request, Contractor shall provide to County a certificate of insurance, a policy, or other proof of insurance as determined in County's sole discretion. County may require Contractor to provide a certificate of insurance naming Weld County, Colorado, its elected officials, and its employees as an additional named insured. c. Subcontractor Insurance. Contractor hereby warrants that all subcontractors providing services under this Agreement have or will have the above -described insurance prior to their commencement of the Work, or otherwise that they are covered by the Contractor's policies to the minimum limits as required herein. Contractor agrees to provide proof of insurance for all such subcontractors upon request by the County. d. No limitation of Liability. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. The County in no way warrants that the minimum limits contained herein are sufficient to protect the Contractor from liabilities that might arise out of the performance of the Work under by the Contractor, its agents, representatives, employees, or subcontractors. The Contractor shall assess its own risks and if it deems appropriate and/or prudent, maintain 5 higher limits and/or broader coverages. The Contractor is not relieved of any liability or other obligations assumed or pursuant to the Contract by reason of its failure to obtain or maintain inaarance in sufficient amounts, duration, or types. The Contractor shall maintain, at its own expense, any additional kinds or amounts of insurance that it may deem necessary to cover its obligations and liabilities under this Agreement. e. Certification of Compliance with Insurance Requirements. The Contractor stipulates that it hai met the insurance requirements identified herein. The Contractor shall be responsible for the professional quality, technical accuracy, and quantity of all services provided, the timely de ivory of said services, and the coordination of all services rendered by the Contractor and shall, without additional compensation, promptly remedy and correct any errors, omissions, or other deficiencies. 14. Indemnity. The Contractor shall defend, indemnify and hold harmless County, its officers, agents, and employees, from and against any and all injury, loss, damage, liability, suits, actions, claims, or willful acts or omissions of any type or character arising out of the Work done in fulfillment of the terms of this Agreement or on account of any act, claim or amount arising or recovered under workers' Qmpensation law or arising out of the failure of the Contractor to conform to any statutes, ordinances, regulation, judicial decision, or other law or court decree. The Contractor shall be fully responsible^ and liable for any and all injuries or damage received or sustained by any person, persons, or property on account of its performance under this Agreement or its failure to comply with the provisions of the Agreement. It is agreed that the Contractor will be responsible for primary loss investigatian, defense, and judgment costs where this contract of indemnity applies. In consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the County its associated and/or affiliated entities, successors, or assigns, its elected officials, trustees, employees agents, and volunteers for losses arising from the work performed by the Contractor for the Count?. A failure to comply with this provision shall result in County's right to immediately terminate dsis Agreement. 15. Non -Assignment. Contractor may not assign or transfer this Agreement or any interest therein or claim thereunder, without the prior written approval of County. Any attempts by Contractor to assign or transfer its rights hereunder without such prior approval by County shall, at the option of County, automatically terminate this Agreement and all rights of Contractor hereunder. Such consent may be granted or denied at the sole and absolute discretion of County. 16. Examination of Records. To the extent required by law, the Contractor agrees that an duly authorized representative of County, including the County Auditor, shall have access to and the right tc examine and audit any books, documents, papers, and records of Contractor, involving all matters and/or transactions related to this Agreement. Contractor agrees to maintain these documents for three years from the date of the last payment received. 17. Interruptions. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires,strikes, war, flood, earthquakes, or Governmental actions. 6 18. Notices. County may designate, prior to commencement of Work, its project representative ("County Representative") who shall make, within the scope of his or her authority, all necessary and proper decisions with reference to the project. All requests for contract interpretations, change orders, and other clarification or instruction shall be directed to County Representative. All notices or other communications made by one party to the other concerning the terms and conditions of this contract shall be deemed delivered under the following circumstances: (a) personal service by a reputable courier service requiring signature for receipt; or (b) five (5) days following delivery to the United States Postal Service, postage prepaid addressed to a party at the address set forth in this contract; or (c) electronic transmission via email at the address set forth below, where a receipt or acknowledgment is required and received by the sending party; or Either party may change its notice address(es) by written notice to the other. Notice may be sent to: TO CONTRACTOR: Name: Bob Dix Position: Therapist/President Address: 1453 Cherrywood Way Address: Longmont, Colorado 80504 E-mail: bobdix.Ipc@gmail.com Phone: (970) 685-7469 TO COUNTY: Name: Jamie Ulrich Position: Director Address: P.O. Box A Address: Greeley, Colorado 80632 E-mail: iulrich(cl..weld.gov Phone: (970) 400-6510 19. Compliance with Law. Contractor shalt strictly comply with all applicable federal and State laws, rules and regulations in effect or hereafter established, including without limitation, laws applicable to discrimination and unfair employment practices. 20. Non -Exclusive Agreement. This Agreement is nonexclusive, and County may engage or use other Contractors or persons to perform services of the same or similar nature. 21. Entire Agreement/Modifications. This Agreement including the Exhibits attached hereto and incorporated herein, contains the entire agreement between the parties with respect to the subject matter contained in this Agreement. This instrument supersedes all prior negotiations, representations, and understandings or agreements with respect to the subject matter contained in this Agreement. This Agreement may be changed or supplemented only by a written instrument signed by both parties. 22. Fund Availability. Financial obligations of the County payable after the current fiscal year are contingent upon funds for that purpose being appropriated, budgeted and otherwise made 7 available. Execution of this Agreement by County does not create an obligation on the part of County to expend funds not otherwise appropriated in each succeeding year. 23. Employee Financial Interest/Conflict of Interest — C.R.S. §§24-18-201 et seq. and §24- 50-507. The signatories to this Agreement state that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. 24. Survival of Termination. The obligations of the parties under this Agreement that by their nature would continue beyond expiration or termination of this Agreement (including, without limitation, the warranties, indemnification obligations, confidentiality and record keeping requirements) shall survive any such expiration or termination. 25. Severability. If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. 26. Governmental Immunity. No term or condition of this Agreement shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections, or other provisions, of the Colorado Governmental Immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 27. No Third -Party Beneficiary. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 28. Board of County Commissioners of Weld County Approval. This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado or its designee. 29. Choice of Law/Jurisdiction. Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 30. Attorney's Fees/Legal Costs. In the event of a dispute between County and Contractor concerning this Agreement, the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf 8 31. Binding Arbitration Prohibited. Weld County does not agree to binding arbitration by any extra judicial body or person. Any provision to the contrary in this Agreement or incorporated herein by reference shall be null and void. 32. Acknowledgment. County and Contractor acknowledge that each has read this Agreement, understands it and agrees to be bound by its terms. Both parties further agree that this Agreement, with the attached Exhibits, is the complete and exclusive statement of agreement between the parties and supersedes all proposals or prior agreements, oral or written, and any other communications between the parties relating to the subject matter of this Agreement. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST:--'dr" lerk to the Board BY: 9 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Kevin D. Ross, Chair JAN 2 4 2024 Crossroadsx Counseling, Professional, LLC 1453 Cherrywood Way Longmont, Colorado 80504-3065 (970) 685-7469 geed ADie By: Robert A Dix (Jan 2, 207417.01.1s, Robert A. Dix, President Date: Jan 2, 2024 go,/ -. (C 9 EXHIBIT A SCOPE OF SERVICES Contractor will provide Sexual Abuse Treatment Services, as referred by the Department. I. Otense Specific Treatment (SOMB) Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Cognitive behavior therapy (CBT) curriculum. b. Anticipated Frequency of Services: i. Four (4) hours per week. c. Anticipated Duration of Services: i. One (I) time per week. d. Goals of Services: i. To consistently understand all types of abuse. ii. Recognize risks. iii. Recognizes his/her cycle and tries to exit the cycle. iv. Use effective coping skills when stressed. v. Able to regulate emotions. vi. Take responsibility for his/her behavior. vii. Manage anger and frustrations when things to not go well. e. Outcomes of Services: i. Thinks ahead and uses safety planning to reduce risks. ii. Use empathy with others. iii. To not try to control other people's behavior. iv. Uses appropriate skills to protect (him/her) self. v. Demonstrate good pro -social skills. vi. Has a good and positive self-image. vii. Able to relax and play. viii. Is able to identify family supports and community supports. ix. Respect authority and limits. x. To adapt when circumstances change. f. Target Population: i. Juveniles or adults who have committed and been sentenced for juvenile sexual offenses. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In office located at 1453 Cherrywood Way, Longmont, Colorado 80504. Terms I . Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. 2. Contractor agrees to receive referrals for services through e-mail and will provide an identified e-mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. 3. Contractor will respond to the Mental Health and Support Services Team If CWServiceReferral(alweldeov.com) within three (3) business days regarding the ability to accept the received referral. 4. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Mental Health and Support Services Team HS- CWServiceReferralCalweldeov.com. 5. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Mental Health and Support Services Team HS- CWServiceReferral(aiweldeov.com. No other Department staff or other party to the case may authorize services or modifications to services. 6. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit B, Rate Schedule, then Contractor understands that the Department will not reimburse for "no-shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 -hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharge the client from services. Contractor must inform the caseworker and the Mental Health and Support Services Team HS-CWServiceReferral atlweldnov.com within three (3) days of when the client is placed on a behavioral plan or discharged 7. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Mental Health and Support Services Team HS- CWServiceReferral(aweldaov.com immediately via email, to discuss service continuation. 8. Contractor will identify, in detail, areas of continued concern and make recommendations to :he caseworker in a monthly report regarding continuation of services and/or the need for additional services. 9. Crntractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 10. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of coicern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported to the caseworker and the Mental Health and Support Services Team HS-CWServiceReferral08welduov.com immediately AND on the required monthly report. 1 1 Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Clinical Care Coordinator or any member of the Mental Health and Support Services Team. Any changes to visitation referrals will be approved by a new referral signed by the Child Welfare Supervisor. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 12. Contractor agrees to attend meetings when available and as requested by the Department. Suds meetings include Court Facilitations, Bid Meetings, Professional Stuffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Mental Health and Support Services Team, and the facilitator documents in the meeting notes the timeframe that the provider attended and when participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the meeting notes. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone or virtually, if approved by the Department. 13. On a monthly basis, the Contractor will notify the Mental Health and Support Services Team HS-CWServiceReferrald weldeov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 14. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas: Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR) and will address the aforementioned three areas when completing monthly reports as required by Paragraph 9 of this Exhibit. 15. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 16. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 17. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e- mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be personally served. 18. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department, and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients to sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. EXHIBIT B RATE SCHEDULE f . Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate(s) specified below in Paragraph 2, Fees for Services. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. For services funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check, deposit slip or bank letter. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. For services not funded through Core Services; Contractor agrees to accept payment through County Warrant when funding source does not allow for direct deposit. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Program Area Sexual Abuse Rate Unit Type Service Name Treatment $110.00 Hour Offense Specific Treatment - In-Office/Video $110.00 Hour Offense Specific Treatment: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $ 50.00 Each Offense Specific Treatment: No -Show 3. Request for Reimbursement and Supporting Documentation Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 45 days from the date of service for each client receiving ongoing services. Contractor shall prepare and submit monthly a Request for Reimbursement and monthly report including other supporting documentation, if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 of this Agreement. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Time(s) of service (i.e. 2-4pm) b. Location of where the service took place (i.e. clinician's office, client's home, in the community.) c. Clinician/therapist name d. What interventions were used, recommendations and/or goals discussed, progressions towards goals, and client engagement. e. For mileage reimbursement, if applicable, the mileage accumulated minus roundtrip mileage that is included in the rate, starting location, and ending location. f. Any and all safety concerns. When submitting a Request for Reimbursement for a one-time service, the contractor shall submit the first and last page of the evaluation/report to confirm proof of services rendered. The full evaluation/report should be submitted by the contractor to the caseworker. For Monitored Sobriety services, proof of services rendered shall be the test result. Requests for Reimbursement and/or supporting documentation received after the 7th day of the month may delay payment. Requests for Reimbursement and/or supporting documentation received after 45 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 45 -day deadline may result in termination of the Agreement. 4. Payment The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: The service being provided by the contractor is not a Medicaid eligible service. a. The service is not deemed medically necessary. b. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used. c. A Medicaid provider is not available to provide the needed service. d. Medicaid is exhausted for the needed service; or e. Medicaid denied service. f. The client is not eligible for Medicaid. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: a. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 6. Financial Management At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMB Circular A-133. Exhibit C WELD COUNTY'S REQUEST FOR PROPOSAL (Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon request to the Department.) This page is intentionally left blank Exhibit D Contractor's response to the Request for Proposal Exhibit D contains the following documents: • Attachment B — Provider Information Form (PIF) • Attachment C — Proposal • Attachment D — Staff Data Sheet • Certificate of Insurance (COI) ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES — PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION Agency Name: Crossroads CounselingX, Professional LLC Provider Contact Full Name: Robert (Bob) A Dix, LPC 970-685-7469 Primary Phone Number (10 -digit): Primary Contact Entail: bobdix.lpc@gmail.com Trails Provider ID (If known): 1588609 Title: therapist / president Ext.: Fax Number (10 -digit): Web Address: 1453 Cherrywood Way, Longmont, CO. 80504 Agency Location Address (street, city, state, zip): 1453 Cherrywood Way, Longmont, CO. 80504 Agency Mailing Address (street, city, state, zip): Agency Type (pick ore): Public Company ® Private Non -Profit © Private for Profit Send Referrals for Service to: Referral Contact Name: Bob Dix, LPC Title: therapist 970-685-7469 Referral Phone Number (10 -digit): Ext.: Email: bobdix.lpc@gmail.com Billing Contact Billing Contact Name: Bob Dix, LPC Title: therapist Billing Phone Number (10 digit): 970-685-7469 Ext.: Email: bobdiXJpc@gmail.com CERTIFICATION T , ' I certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the specifications it' has so indicated in this bid form. I further affirm intention to enter into an agreement with Weld County, on behalf of the Weld County Department of Human Services, and comply with all requirements of the contract, if awarded. The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to accept Ithe bid, or part of a bid, that, in the opinion of the Board, is in the best interests of the Board and of the County of Weld, State of Colorado. The Board of Weld County Commissioners shall give preference to resident Weld County bidders in all cases where the bids are competitive in price and quality. WELD COUNTY IS EXEMPT FROM COLORADO SALES TAXES. THE CERTIFICATE OF EXEMPTION NUMBER IS #98-03551-0000. Authorized Rep. Full Name: Bob Dix, LPC Title: therapist Authorized Rep. Email: 970-685-7469 com Phone (10 -digit): Ext.: Authorized Rep. Address (street city, state, zip): 1453 Cherrywood Way, Longmont, CO. 80504 ,'obat A Dix ature of Authorized Rep.: Robert A Dix (Jan 2, 202417:01 MST) Date: 1-2-2034 REV. DECEMBER 2021 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Crossroads Counseling / Robert (Bob) A Dix Program Area: Number of services offered on this Attachment C Sexual Abuse Treatment (max 5): Program Areas are listed in column 1 of the table located in item XI of the Request for You may complete another Attachment C if you have more than S. Proposal starting on page 13. 1 If the Service 2.1a 2.1b 2.1c 2.1d 2.10 2.1f 2.1g 2.1h 2.1i Service 2.2a SECTION 2 — Service Name(s) and Information service is a monthly package, please offer different levels. All monthly packages must state a specific minimum number of direct service hours. #1 Name: I Offense specific treatment (SOMB) Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): I Modality: CBT: curriculum — individualized curricula, treatment addresses desired outcomes in SOMB Standards 3.150 I Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: Once a week - could be individual or family ____I Anticipated duration of service (i.e. 3-4 months): I Up to 2 years of probation —at the discretion of the MDT I Three (3), or more, specific goals of the service (DO use bullet points): I treatment addresses the 17 desired outcomes in SOMB Standards 3.150 I Three (3), or more, specific outcomes of service: I treatment addresses the 17 desired outcomes in SOMB Standards 3.150 1 Target population of the service, including age and gender: I Juveniles or adults who have committed & sentenced for juvenile sexual offenses I Languages service is available in (please list proficiency and if interpreter services are available): I English I Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: I none I Service location — list where the service will take place (i.e. client's home, in -office, other) I in -office -- Longmont I #2 Name: Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): I 2.2b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: I I 2.2c Antidpated duration of service (I.e. 3-4 months): I I 2.2d Three (3), or more, specific goals of the service (DO use bullet points): ( 2.2e Three (3), or more, specific outcomes of service: 2.2f Target population of the service: I 2.2g Languages service is available in (please list proficiency and if Interpreter services are available): I 2.2h 2.21 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: I Service location — list where the service will take place (i.e. client's home, in -office, other) [ I REV. OCT 2021 ATTACHMENT C - PROPOSAL Service #3 Name: 2.3a Modalities, curiculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): l l 2.3b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrativeeime, overhead, or travel time (I.e. 4 hours/week). If the service has levels, be specific for each level: 2.3c Anticipated duration of service (i.e. 3-4 months): 2.3d Three (3), or pore, specific goals of the service (DO use bullet points): 2.3e Three (3), or more, specific outcomes of service: 2.3f Target population of the service: 2.3g Languages service is available in (please list proficiency and if interpreter services are available): 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2.3i Service location — list where the service will take place (i.e. client's home, in -office, other) Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d ( Three (3), or more, spycific goals of the service (DO use bullet points): 2.4e Three (3), or mere, specific outcomes of service: 2.4f Target population of the service: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2.4i Service location — list where the service will take place (i.e. client's home, in -office, other) Service #5 Name: 2.5a Modalities, curiculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.5b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative lime, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: REV. OCT 2021 ATTACHMENT C - PROPOSAL 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part 2.6i Service location — list where the service will take place (Le. client's home, in -office, other) Section 3 — Service Access and Transportation 3.1 Will you charge Weld County for transporting clients or mileage? Check one: 0 YES (8 NO 3.2 Will you conduct services in a client's home or in the community? Check one: 0 YES • NO 3.3 Will you transport clients to and/or from services? Check one: 0 YES ® NO 3.4 How many miles are you willing to travel round trip? List a specific number of miles. 3.5 When you calculate mileage, what is your starting point address? Miles SECTION 4 - SERVICE RATES All rates need to include administrative work (i.e. scheduling or report writing) and overhead. Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except for those listed above. • For hourly rates complete section(s) 4.1-4.5. • For monthly rates complete section 4.6. • For Home study providers complete section 4.7. • For monitored sobriety testing providers complete section 4.8. 4.1 Hourly Service #1 Name: Crossroads Counseling 4.1a In-Office/Video: 4.1b In -Home or Community: 4.1c In-Office/Video, In -Home, or Community with Transportation: 4.1d FTM, TDM, Prof. Staffing: 4.1e No show: 4.1f Mileage rate: $ Amount Unit Type 110 110 50 per hour Select Unit Type. Select Unit Type. per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles Included in rate: This is paid after the miles listed above. miles miles 4.2 Hourly Service #2 Name: 4.2a In-Office/Video: 4.2b In -Home or Community: 4.2c In-Office/Video, In -Home, or Community with Transportation: 4.2d FTM, TDM, Prof. Staffing: 4.2e No show: 4.2f Mileage rate: $ Amount Unit Type Select Unit Type. Select Unit Type. Select Unit Type. per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included In rate: miles miles This is paid after the miles listed above. 4.3 Hourly Service #3 Name: REV. OCT 2021 ATTACHMENT C - PROPOSAL $ Amount Unit Type 4.3a In-Office/Video: Select Unit Type. 4.3b In -Home or Community: Select Unit Type. No. of roundtrip miles included in rate: miles 4.3c In-Office/Video, In -Home, or Community with Transportation: Select Unit Type. No. of roundtrip miles included in rate: miles 4.3d FTM, TDM, Prof. Staffing: per Hour 4.3e No show: per No Show 4.3f Mileage rate: per Mile This is paid after the miles listed above. 4.4 Hourly Servicet4 Name: $ Amount Unit Type 4.4a In-Office/Video: Select Unit Type. 4.4b In -Home or Community: Select Unit Type. No• of roundtrip miles included in rate: miles 4.4c In-Office/Video, In -Home, or Community with Transportation: Select Unit Type. No. of roundtrip miles included in rate: miles 4.4d FTM, TDM, Prof. Staffing: per Hour 4.4e No show: per No Show 4.4f Mileage rate: per Mile This is paid after the miles listed above. 4.5 Hourly Service e5 Name: $ Amount Unit Type 4.5a In-Office/Video: Select Unit Type. 4.5b In -Home or Community: Select Unit Type. No. of roundtrip miles included in rate: miles 4.Sc In-Office/Video, In -Home, or Community with Transportation: Select Unit Type. No. of roundtrlp miles included in rate: miles 4.5d FTM, TDM, Prof. Staffing: per Hour 4.5e No show: per No Show 4.5f Mileage rate: per Mile This is paid after the miles listed above. 4.6 Monthly Service Rates (each level must be fisted): Service Name with Level Rate per Month Minimum Hours of Service: 4.6a Offense specific hourly rate $110/hour Min: 5 hrs (4 hrs therapy 1 hr staffing) 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4.7 Home Study Providers — list your rates in the box below. 1 4.8 Monitored Solxiety Providers — List your rates in the box below. REV. OCT 2021 4 ATTACHMENT D - STAFF DATA SHEET Bidder Must List All Staff Who Will Administer the Proposed Service(s) BIDDER'S LEGAL NAME (As it appears on the W-9): AGENCY CONTACT: Bob Dix, LPC Crossroadsx Counseling Professional LLC PHONE NUMBER: 970-685-7469 EMAIL: bobdix.lpc@gmail.com PROPOSED SERVICE(S): SOMB offense specific therapy for juveniles who have committed sexual offenses Legal Last Name Middle Initial Previous Legal Last Name (If applicable) Legal First Name Service Type Licensure/ Credentials DORA # (If applicable) Dix A Robert (Bob) therapy LPC 5387 SOMB ull operating treatment provids CHILD WELFARE REQUEST FOR PROPOSAL 2023-24 - VARIOUS SERVICES Account Number: CO CROS 1450 Date: 12/22/23 Initials: QTMHHTTP CERTIFICATE OF INSURANCE ALLIED WORLD INSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800-421-6694 This is to certify that the insurance policies specified below have been issued by the company indicated above uo the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of tae Named Insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) .#FFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Named Insured: Additional Named Insureds: CROSSROADSX COUNSELING ROBERT A DIX PROFESSIONAL LLC 1453 CHERRYWOOD WAY LONGMONT CO 80504 Type of Work Covered: MENTAL HEALTH COUNSELOR Location of Operations: N/A (If different than address listed above) Claim History: None Retroactii.+e date is 03/28/202 Coverages Policy Number Effective Date Expiration Date Limits of Liability PROFESSIONAL/ LIABILITY 5006-4899 3/28/2023 3/28/2024 1,000,000 1,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: Defense Reimbursement Proceedings Limit is $5,000. 1 ADDL.INS.BELOW: BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY & ITS OFFICERS/ EMPLOYEES CO 80631 This Certificate Issued to: Name: Board County Commissioners - Weld County and its officers / employees Address: Weld County 1150 "O" Street Greeley, CO. 80631 APA 00138 00 (06/2014) Authorized Representative SIGNATURE REQUESTED: Weld/Crossroadsx PSA Final Audit Report 2024-01-03 Created: 2024-01-02 By: Windy Luna (wluna@co.weld.co.us) Status: Signed Transaction ID: CBJCHBCAABAAzEZ2oncRSfaLnkIMYPSyvV1xg2Eaay_P "SIGNATURE REQUESTED: Weld/Crossroadsx PSA" History ,n Document created by Windy Luna (wluna@co.weld.co.us) 2024-01-02 -10:10:38 PM GMT Mr Document emailed to bobdix.Ipc@gmail.com for signature 2024-01-02 -10:11:17 PM GMT n Email viewed by bobdix.Ipc@gmail.com 2024-01-02- 10:22:07 PM GMT 2 j Signer bobdix.Ipc@gmail.com entered name at signing as Robert A Dix 2024-01-03 - 0:01.36 AM GMT 6a Document e -signed by Robert A Dix (bobdix.lpc@gmail.com) Signature Date: 2024-01-03 - 0:01:38 AM GMT - Time Source: server d Agreement completed. 2024-01-03 - 0:01:38 AM GMT Pccn'a by Adobe Acrobat Sign ontract F Entity Information Entity Name* CROSSROADS COUNSELING PROFESSIONAL LLC Entity ID* @00034180 Contract Name* CROSSROADSX COUNSELING PROFESSIONAL, LLC (NEW POST -BID PROVIDER B2300040) Contract Status CTB REVIEW O New Entity? Contract ID 7729 Contract Lead * WLUNA Contract Lead Email wluna@weldgov.com;cob bxxlk@weldgov.com Parent Contract ID Requires Board Approval YES Department Project # Contract Description * NEW POST -BID #B2300040 - PROFESSIONAL SERVICES AGREEMENT. TERM: JANUARY 1, 2024 THROUGH MAY 31, 2024. Contract Description 2 PA ROUTING THROUGH NORMAL PROCESS. ETA TO CTB 01/11/2024. Contract Type" AGREEMENT Amount* $0.00 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServices@weldgov. com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WEL DGOV.COM Requested BOCC Agenda Date * 01/17/2024 Due Date 01/13/2024 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Termination Notice Period Contact Information Review Date" 03/29/2024 Committed Delivery Date Renewal Date Expiration Date* 05/31/2024 Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date Approval Process Department Head Finance Approver Legal Counsel JAMIE ULRICH CHERYL PATTELLI BYRON HOWELL DH Approved Date Finance Approved Date Legal Counsel Approved Date 01/11/2024 01/12/2024 01/12/2024 Final Approval BOCC Approved Tyler Ref # AG 012424 BOCC Signed Date Originator WLUNA BOCC Agenda Date 01/24/2024 Hello