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Home My WebLink About20241324.tiffCoinrack PROFESSIONAL SERVICE AGREEMENT BETWEEN WELD COUNTY AND SOVEREIGNTY COUNSELING SERVICES, PLLC THIS AGREEMENT is made and entered into this ZZ.nday of 2024, by and between the Board of Weld County Commissioners, on behalf of the Weld C my Department of Human Services, hereinafter referred to as "County," and Sovereignty Counseling Services, PLLC, 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 Foster Care/Adoption Support, Life Skills, Mental Health Services, Foster Parent Training, and Therapeutic Kinship 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 based upon order of attachment. Exhibit A consists of the Scope of Services. Exhibit B consist of the Rate Schedule. Exhibit C consists of County's Request for Proposal (RFP) as set forth in Bid Package No. B2400040 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. cc:Conwi+ 1011d -id& ,-/.1,2/4 5/ZUZ4{ maOOoiti2 2024-1324 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 with 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 June 1, 2024, through May 31, 2027, unless sooner terminated as provided herein, and is subject to continued budget appropriations. 4. Termination; Breach; Cure. County may terminate this Agreement for its own convenience 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 claim 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. 2 6. Compensation. County agrees to pay Contractor through an invoice process during the course of this 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 invoice 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 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 3 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, 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 such material for purposes other than in connection with this Agreement without prior written approval of County. 10. Confidentiality. 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 must comply with the provisions of the Colorado Open Records Act (CORA), C.R.S. 24-72-201, et seq., 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. Acceptance 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. Acceptance 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 this 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 4 or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the County of, or payment for, the Work completed 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 required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, and during any warranty period. For all coverages, Contractor's insurer shall waive subrogation rights against County. a. Types of Insurance. 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. 5 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 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 insurance 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 has 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 delivery 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' compensation 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 investigation, 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 6 entities, successors, or assigns, its elected officials, trustees, employees, agents, and volunteers for losses arising from the work performed by the Contractor for the County. A failure to comply with this provision shall result in County's right to immediately terminate this 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 maybe 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 a duly authorized representative of County, including the County Auditor, shall have access to and the right to 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. 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: Annette Brown Position: Owner/Therapist Address: 2580 East Harmony Road, Suite 201 Address: Fort Collins, Colorado 80528 E-mail: info@sovereigntycounseling.com Phone: (970) 964-3133 7 TO COUNTY: Name: Jamie Ulrich Position: Director Address: P.O. Box A Address: Greeley, Colorado 80632 E-mail: julrich@weld.gov Phone: (970) 400-6510 19. Compliance with Law. Contractor shall 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 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. Contractor agrees that if Contractor employs a former employee of the Department of Human Services, Contractor will notify the County within 30 days of employment. The Contractor will also abide by applicable requirements under C.R.S. 24-18- 201 et seq. 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. 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. 9 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: ' - A) BY: to the Board Deputy Clerk o th- Boar 10 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO D Kevin D. Ross, Chair MAY 2 2 2024 CONTRACTOR: Sovereignty Counseling Services, PLLC 2580 East Harmony Road, Suite 201 Fort Collins, Colorado 80528 By: Annett r n (hlay 8.202419:06 MDT, Annette Brown, Owner/Therapist Date: May 8, 2024 /c' 024 EXHIBIT A SCOPE OF SERVICES Contractor will provide Foster Care/Adoption Support, Life Skills, Mental Health Services, Foster Parent Training, and Therapeutic Kinship Services, as referred by the Department. Foster Care/Adoption Support 1. Foster Parent Consultation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Psychoeducation. ii. Strategic therapy to address family interaction and effective communication. iii. Therapeutic Games and Homework assignments. iv. Incredible Years skills/principles for foster parents of children three (3) to seven (7) years old. v. Reality Therapy. vi. Systemic -Attachment Informed Eye Movement Desensitization and Reprocessing (EMDR). b. Anticipated Frequency of Services: i. One (1) to four (4) hours per week. c. Anticipated Duration of Services: i. One (1) to three (3) months. d. Goals of Services: i. Minimize the traumatic effects on the child(ren) being removed their home or previous placement. ii. Develop foster environments capable of responding to the "whole child", including emotional and behavioral needs of neglected and abused children. iii. Provide education and support to foster parents. e. Outcomes of Services: i. Reduce effects of trauma on the child(ren) who have been removed from their home or previous placement. ii. Have competent and confident foster parents capable of responding to the "whole child" including the emotional and behavioral needs of neglected and abused children. iii. Provide Foster parents with foundational knowledge regarding trauma, abuse and neglect, transitions, mental health system navigation, reunification, and baseline information about developmentally appropriate expectations and behaviors within the context of child welfare. f. Target Population: i. Families with children in out -of -home placement who are referred through the Family Courts for parent -child visitation from the Department with visitation needs in Weld County. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -Office. ii. In Home or Community. Life Skills 1. Therapeutic Family Time a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Strategic Therapy Principles. ii. Psychoeducation. iii. Therapeutic Games and Homework. iv. Strength Based, Present -focused feedback. v. Incredible Years skills/principles for foster parents of children ages three (3) to seven (7). b. Anticipated Frequency of Services: i. Two (2) to four (4) hours per week. c. Anticipated Duration of Services: i. One (1) to six (6) months as needed or court ordered. d. Goals of Services: i. Provide a safe, welcoming environment to hasten the reunification process. ii. Increase parent/child bonding. iii. Increase knowledge of appropriate parenting skills and capability to provide for children's needs. iv. Provide references and link families to additional services when necessary to meet children's special physical and mental need. v. Provide therapeutic intervention and address barriers in parent/child relationships. e. Outcomes of Services: i. Established, maintained, or strengthened family relationships. ii. Enhanced well-being of child(ren) and reduced trauma/effects of separation. iii. Increased parenting skills and confidence to provide for children's needs. iv. Measurable increased growth in regard to parenting skills. v. Barriers to parent/child relationship addressed/resolved. f. Target Population: i. Families with children in out -of -home placement who are referred through the Family Courts for parent -child visitation from the Department with visitation needs in Weld County. g. Language: i. English. h. Medicaid Eligibility: i. This service is Medicaid eligible. i. Service Access and Transportation: i. In -Office. ii. In -Home or Community. Mental Health Services 1. Family Therapy a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Multisystemic Therapy Theory. ii. Eye Movement Desensitization and Reprocessing (EMDR). iii. Cognitive Behavioral Therapy (CBT). iv. Mindfulness. v. Psychoeducation. vi. Therapeutic Homework. b. Anticipated Frequency of Services: i. One and a half (1 4) to four (4) hours per week. c. Anticipated Duration of Services: i. Three (3) to six (6) months. d. Goals of Services: i. Provide diagnostic and/or therapeutic services to assist in the development of family services plan. ii. Assess and/or improve family communication, functioning and relationships. iii. Improve the family or dyad's mental health and or relationship, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. iv. Explore family welfare specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resiliency. v. Reprocess maladaptive neuropathways consequences of loss, grief, abuse, and neglect to increase adaptive and resilient responses. e. Outcomes of Services: i. Family member's mental health needs will be addressed related to loss, grief, abuse, neglect, and assist in building resiliency. ii. Family members can access adaptive neuropathways to utilize in regulating emotions and response to life stress and triggers related to experienced trauma. iii. Improved family communication, functioning and relationships. f. Target Population: i. Family dyads or groups with children zero (0) to eighteen (18) years old experiencing mental health symptoms due to trauma related loss, grief, abuse, neglect, and who require assistance in building resiliency, who are receiving co-occurring services (such as families with children in out -of - home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time) from the local department of Social Services or Kinship Caretakers. g. Language: i. English. h. Medicaid Eligibility: i. This service is Medicaid eligible. i. Service Access and Transportation: i. In -Office. ii. In -Home or Community. 2. Individual Therapy a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Eye Movement Desensitization and Reprocessing (EMDR). ii. Cognitive Behavioral Therapy (CBT). iii. Motivational Interviewing. iv. Psychoeducation. v. Mindfulness Therapeutic Homework. b. Anticipated Frequency of Services: i. One (1) to two (2) hours per week. c. Anticipated Duration of Services: i. Three (3) to six (6) months, as needed or court ordered. d. Goals of Services: i. Provide diagnostic and/or therapeutic services. ii. Improve the client's mental health, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. iii. Address client welfare -specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resilience. iv. Reprocess maladaptive neuropathway consequences of loss, grief, abuse, and neglect to increase adaptive and resilient responses. v. Decrease or eliminate psychological and somatic suffering due to maladaptive memory storage of sexual trauma. vi. Reprocess maladaptive neuropathways related to sexual trauma. vii. Increasing adaptive response and regulation to triggers related to trauma. e. Outcomes of Services: i. Improved client mental health and impacts of mental health. ii. Client mental health needs will be addressed related to loss, grief, abuse, neglect, and assist in building resiliency. iii. Client accesses adaptive neuropathways to utilize in regulating emotions and response to life stress and triggers related to experienced trauma. iv. Decreased/Eliminated suffering related to sexual trauma. v. Increased adaptive ability to respond to triggers and life stress. f. Target Population: i. Individuals three (3) years and older experiencing mental health symptoms due to trauma related loss, grief, abuse, neglect, and assist in building resiliency, who are receiving co-occurring services, including individuals in out -of -home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time, from the local department of Social Services or Kinship Caretakers. g. Language: i. English. h. Medicaid Eligibility: i. This service is eligible for Medicaid. i. Service Access and Transportation: i. In -Office. ii. In -Home or Community. Foster Parent Training 1. Foster Parent Training a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Psychoeducation. b. Anticipated Frequency of Services: i. Ninety (90) to one hundred twenty (120) minutes per training. c. Anticipated Duration of Services: i. One (1) to twelve (12) trainings per year. d. Goals of Services: i. Prepare and support foster parents in providing nurturing care in a safe and healthy environment. ii. Prepare and support foster parents in meeting the developmental and emotional needs of the children. iii. Develop skills in trauma informed parenting skills. iv. Develop and promote skills in protecting and promoting the child's cultural identity and heritage. v. Develop and promote the child's connection to his or her own family as appropriate. e. Outcomes of Services: i. Ongoing preparation and support for foster parents in meeting the needs of children who have been abused and neglected. ii. Increased ability to address trauma response behaviors in foster children effectively and compassionately. iii. Competent and compassionate foster parents who provide care in a safe and healthy environment. f. Target Population: i. Prospective and current foster parents within the Department. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -Office. ii. In -Home. Therapeutic Kinship Services 1. Kinship Consultation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Psychoeducation. ii. Strategic therapy to address family interaction and effective communication. iii. Therapeutic Games and Homework assignments. iv. Reality Therapy. v. Systemic -Attachment Informed Eye Movement Desensitization and reprocessing (EMDR). b. Anticipated Frequency of Services: i. One (1) to four (4) hours per week. c. Anticipated Duration of Services: i. One (1) to three (3) months as needed. d. Goals of Services: i. To Strengthen, preserve, and promote positive relationships between child, parents, family members. ii. Observe current individual and family functioning to identify specific goals. iii. Decreasing conflict in the home. iv. Building resiliency within the children and family. e. Outcomes of Services: i. Decreased conflict in the home. ii. Resilient and confident individuals and family system. iii. Continuing needs of individuals and family are identified to be addressed further. f. Target Population: i. Kinship households and families with children ages birth to eighteen (18) years old who are receiving co-occurring services, such as families with children in out -of -home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time, from the local department of Social Services or Kinship Caretakers English speaking participants and families, unless interpreter is provided by Weld County. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -Office. ii. In -Home or Community. Terms 1. 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 (HS- CWServiceReferral@weld.gov) 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- CWServiceReferral@weld.gov. 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@weld.gov. 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" 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@weld.gov 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@weld.gov immediately via email, to discuss service continuation. 8. Contractor will identify, in detail, areas of continued concern and make recommendations to the caseworker in a monthly report regarding continuation of services and/or the need for additional services. 9. Contractor 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 concern 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-CWServiceReferral@weld.gov immediately AND on the required monthly report. 11. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Mental Health and Support Services Team. Any changes to Family Time 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. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, 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 Mental Health and Support Services Team. 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-CWServiceReferral@weld.gov 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. Trainin 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 1. 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 Foster' re/Adoption Support Rate 100.00 Unit Type Service Name Hour Foster Parent Consultatl TDM, Professional Staffs Foster Parent Consultation: In- Home/Community ig $ 160.00 Hour Parent Cc t Video ultatii 0.64 Mile Foster Parent Consultation: Mileage Life Skills $ 100.00 Each Hour er Parent Consultation: No Show Therapeutic Family Time: FTM, TDM, Professional Staffing $ 120.00 Hour Hour e1 tie Family Ti mmonity e: fn Therapeutic Family Time: In- Office/Video Program Area Unit Type Service Name 64 Mite $ 120.00 Each Therapeutic Family Time: No Show Ho $ 140.00 Hour Family Therapy: In-Office/Video .00 Each Sf $ 160.00 Hour Individual Therapy: In -Home or Community Individual Therapy: In-Office/Video 40.00 $ 120.00 Hour Each Individual Therapy: No Show TDM, Hour 0.64 Mile Mental Health Services: Mileage Foster Pa T 350,00 $ 300.00 Episode. Episode e or Foster Parent Training: In-Office/Video 0,64 Fite Foster P Tl 61 $ 120.00 Each Foster Parent Training: No Show Kinshi 100.©0 $ 160.00 Hour Kinship Consultation: In- Home/Community 140.00 K deo 0.64 Mile Kinship Consultation: Mileage 20.00 phi 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) - - - - - a - a a - - IS - - - - - - - -------------------------------------------- CERTIFICATION - - a - - - a a - - a a 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 informal ty in the bids, and to accept the 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: Authorized Rep. Email: Annette Brown annette@sovereigntycounseling.com Authorized Rep. Address (Street, city, state, zip): L.' ----- ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES - PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION SovereigntyCou nseli n ServicesAgency Name.g Trails Provider ID (if known): Annette Brown LM FT Provider Contact Full Name: Title.. (970)964-3133 Fax Number(10-digit): (866) 598-4617 Primary Phone Number (10 digit). Ext.: u iinfo@sovereigntycounseling.com Primary Contact Email: Agency Location Address (Street, city, state, zip): Agency Mailing Address (Street, city, state, zip): Agency Type (pick one): Public Company Web Address: https://www.sovereigntycounseling.com/ 2580 E Harmony Rd Ste 201, Fort Collins, CO 80528 2580 E Harmony Rd Ste 201, Fort Collins, CO 80528 H Private Non -Profit Iv Private for Profit Referral Contact Name: Send Referrals for Service to: Annette Brown Referral Phone Number (10 -digit): 970-964-3133 Ext.: Title: Owner/ Therapist Email: annette@sovereigntycounseling.com Billing Contact Name: Billing Contact Molly Wilson Billing Phone Number (10 -digit): 970-964-9133 Title: Executive Business Manager Ext.: Email: molly@sovereigntycounseling.com r I I I I I I I I I I I I a I i I I I I I i Sinature of Authorized Rep.: ----- ---— -- - - -- -- - - a - IN In a — a - — - - — - a Title: -- Owner/Therapist 970-964-3133 ( g) Phone ;t : 10 -di Ext.: 2580 E Harmony Rd. Ste 201 Ft Collins, CO 80528 Date: a - a a - a a - a a a a 1 I e I i I I I i i 01-18-2024 i aa a a __ __ a REV. DECEMBER 2021 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. Provider Information Bidder's Legal Name: (As reflected on W-9) Sovereignty Counseling Services Number of services offered on this Attachment C (max 5): You may complete another Attachment Cif you have more than 5. 5 Service #1 Service Name: Individual Therapy Program Area: Mental Health 1.1 Scope of Work Please Note: If the service is a monthly package, different levels should be indicated. All monthly packages must state a specific minimum number of direct service hours. (Please address each line item belong bu Modalities, curriculum, tools used in delivery of service (DO NOT list company history): • EMDR • CBT • Motivational Interviewing • Psychoeducation • Mindfulness Therapeutic Homework 1.2 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: 1-2 hours a week 1.3 Anticipated duration of service (i.e. 3-4 months): 1.4 3-6 months Three (3), or more, specific goals of the service (DO use bullet points): • To provide diagnostic and/or therapeutic services • To improve the client's mental health, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. • Address client welfare -specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resilience. • Reprocess maladaptive neuropathway consequences of loss, grief, abuse and neglect to increase adaptive and resilient responses. • To decrease or eliminate psychological and somatic suffering do to maladaptive memory storage of sexual trauma. • To reprocess maladaptive neuropathways related to sexual trauma • To increasing adaptive response and regulation to triggers related to trauma 1.5 Three (3), or more, specific outcomes of service: • Improved client mental health and impacts of mental health. • Client mental health needs addressed related to loss, grief, abuse, neglect, and assist in building resiliency • Client accesses adaptive neuropathways to utilize in regulating emotions and response to life stress and triggers related to experienced trauma. • Decreased/Eliminated suffering related to sexual trauma • Increased adaptive ability to respond to triggers and life stress 1.6 Target population of the service, including age and gender: Individuals 3+ years old experiencing mental health symptoms due to trauma related loss, grief, 1 REV. OCT 2023 ATTACHMENT C - PROPOSAL abuse, neglect, and assist in building resiliency, who are receiving co-occurring services (including individuals in out -of -home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time) from the local department of Social Services or Kinship Caretakers 1.7 Languages service is available in (please list proficiency and if interpreter services are available): English 1.8 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Yes 1.9 Service location — list where the service will take place (i.e. client's home, in -office, other) In office, home, or community. Rates Please Note: All rates need to include overhead and administrative work (i.e., scheduling or report writing). All rates should be per hour unless service is for evaluations/assessments, Home Studies or Monitored Sobriety. • For hourly Service rates please complete section 1.10 • For monthly Service rates please complete section 1.11 • For Home Study Providers please complete section 1.12 • For monitored Sobriety Providers please complete section 1.13 1.10 Hourly Service Rates: Service #1 Service Type $ Amount Unit Type 1.10a In-Office/Video 140 Per Hour 1.1ob In -Home Community or 160 Per Hour 1.10c Service Trarsportation Provided with N/A Select Unit Type. 1.10d FTM, TDM, Staffing Prof. 100 per Hour 1.10e No show 120 per No Show 1.10f Mileage rate .64 per Mile 1.11 Monthly Service Rates (each level must be listed): If applicable Service Name with Level Mileage rate is paid after Rate per Month 30 roundtrip miles. Minimum Hours of Service: 1.12 Home Study Providers — List your rates in the box below. 1.13 Monitored Sobriety Providers — List your rates in the box below. REV. OCT 2023 ATTACHMENT C - PROPOSAL Additional Comments 1.14 Weld County Use Only REV. OCT 2023 ATTACHMENT C - PROPOSAL Service #2 Service Name: Program Area: Family Therapy Mental Hea►tk--1, i Scope of Work Please Note: If the service is a monthly package, different levels should be indicated. All monthly packages must state a specific minimum number of direct service hours. (Please address each line item below using buffetedpoints) 2.1 Modalities, curriculum, tools used in delivery of service (DO NOT list company history): • Multisystemic Therapy Theory • EMDR • CBT • Mindfulness • Psychoeducation • Therapeutic Homework 2.2 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: 1.5-4 hours per week 2.3 Anticipated duration of service (i.e. 3-4 months): 3-6 months 2.4 Three (3), or more, specific goals of the service (DO use bullet points): • To provide diagnostic and/or therapeutic services to assist in the development of family services plan • To assess and/or improve family communication, functioning and relationships. • To improve the family or dyad's mental health and or relationship, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. • Explore family welfare specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resiliency. • Reprocess maladaptive neuropathways consequences of loss, grief, abuse and neglect to increase adaptive and resilient responses. 2.5 Three (3), or more, specific outcomes of service: • Family member's mental health needs addressed related to loss, grief, abuse, neglect, and assist in building resiliency • Family members can access adaptive neuropathways to utilize in regulating emotions and response to life stress and trigge�s related to experienced trauma. • Improved family communication, functioning and relationships. 2.6 Target population of the service, including age and gender: Family dyads or groups with children 0-18 years old experiencing mental health symptoms due to trauma related loss, grief, abuse, neglect, and assist in building resiliency, who are receiving co-occurring services (such as families with children in out -of -home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time) from the local department of Social Services or Kinship Caretakers. 2.7 Languages service is available in (please list proficiency and if interpreter services are available): English 2.8 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Yes 2.9 Service location — list where the service will take place (i.e. client's home, in -office, other) In office, home, or community. Rates Please Note: All rates need to include overhead and administrative work (i.e., scheduling or report writing). All rates should be per hour unless service is for evaluations/assessments, Home Studies or Monitored Sobriety. • For hourly Service rates please complete section 2.10 REV. OCT 2023 ATTACHMENT C - PROPOSAL • For monthly Service rates please complete section 2.11 • For Home Study Providers please complete section 2.12 • For monitored Sobriety Providers please complete section 2.13 2.10 Hourly Service Rates: Service #2 Service Type $ Amount Unit Type 2.10a In-Office/Video 140 Per Hour 2.10b In -Home or Community 180 Per Hour 2.10c Transportation Service Provided with N/A Select Unit Type. 2.10d FTM, Staffing TDM, Prof. 100 Per Hour 2.10e No show 140 per No Show 2.10f Mileage rate 64 per Mile 2.11 Monthly Service Rates (each level must be listed): If applicable Service Name with Level 2.11a 2.11b 2.11c 2.11d 2.11e 2.11f 2.11g 2.11h 2.11i 2.11j Mileage rate is paid after 30 roundtrip miles. Rate per Month Minimum Hours of Service: 2.12 Home Study Providers — List your rates in the box below. 2.13 Monitored Sobriety Providers — List your rates in the box below. Additional Comments 2.14 Weld County Use Only REV. OCT 2023 5 ATTACHMENT C - PROPOSAL Service #3 Service Name: Program Area: Kinship Consultation Therapeutic Kinship Services Scope of Work Please Note: If the service is a monthly package, different levels should be indicated. All monthly packages must state a specific minimum number of direct service hours. (Please address each line item below using bulleted points) 3.1 Modalities, curriculum, tools used in delivery of service (DO NOT list company history): • Psychoeducation • Strategic therapy to address family interaction and effective communication. • Therapeutic Games and Homework assignments • Reality Therapy • Systemic -Attachment Informed EMDR 3.2 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: 1-4 hours per week 3.3 Anticipated duration of service (i.e. 3-4 months): 1-3 months; as needed; 3.4 Three (3), or more, specific goals of the service (DO use bullet points): • Strengthen, preserve and promote positive relationships between child, parents, family members. • Observe current individual and family functioning to identify specific goals • Decreasing conflict in the home • Building resiliency within the children and family 3.5 Three (3), or more, specific outcomes of service: • Decreased conflict in the home • Resilient and confident individuals and family system • Continuing needs of individuals and family are identified to be addressed further 3.6 Target population of the service, including age and gender: Kinship households and families with children ages birth to 18 -years -old who are receiving co-occurring services (such as families with children in out -of -home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time) from the local department of Social Services or Kinship Caretakers English speaking participants and families, unless interpreter is provided by Weld County. 3.7 Languages service is available in (please list proficiency and if interpreter services are available): English 3.8 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: No 3.9 Service location — list where the service will take place (i.e. client's home, in -office, other) In office, home, or community. Rates Please Note: All rates need to include overhead and administrative work (i.e., scheduling or report writing). All rates should be per hour unless service is for evaluations/assessments, Home Studies or Monitored Sobriety. • For hourly Service rates please complete section 3.10 • For monthly Service rates please complete section 3.11 • For Home Study Providers please complete section 3.12 • For monitored Sobriety Providers please complete section 3.13 3.10 Hourly Service Rates: Service #3 Service Type $ Amount Unit Type 3.10a In-Office/Video 140 Per Hour REV. OCT 2023 ATTACHMENT C - PROPOSAL 3.10b In -Home or Community 160 Per Hour 3.10c Transportation Service Provided with N/A Select Unit Type. 3.10d FTM, TDM, Staffing Prof. 100 per Hour 3.10e No show 120 per No Show 3.10f Mileage rate .64 per Mile 3.11 Monthly Service Rates (each level must be listed): If applicable Service Name with Level 3.11a 3.11b 3.11c 3.11d 3.11e 3.11f 3.11g 3.11h 3.11i 3.11j Mileage rate is paid after 30 roundtrip miles. Rate per Month Minimum Hours of Service: 3.12 Home Study Providers — List your rates in the box below. 3.13 Monitored Sobriety Providers — List your rates in the box below. Additional Comments 3.14 Weld County Use Only REV. OCT 2023 7 ATTACHMENT C - PROPOSAL Service #4 Service Name: Foster Parent Consultation Program Area: Foster Care/Adoption Support Scope of Work Please Note: If the service is a monthly package, different levels should be indicated. All monthly packages must state a specific minimum number of direct service hours. (Please address each line iteow using bulleted points) 4.1 Modalities, curriculum, tools used in delivery of service (DO NOT list company history): • Psychoeducation • Strategic therapy to address family interaction and effective communication. • Therapeutic Games and Homework assignments • Incredible Years skills/principles (for foster parents of children 3-7 years old) • Reality Therapy • Systemic -Attachment Informed EMDR 4.2 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: 1-4 hours per week 4.3 Anticipated duration of service (i.e. 3-4 months): 1-3 months; as needed 4.4 Three (3), or more, specific goals of the service (DO use bullet points): • To minimize the traumatic effects on the child(ren) being removed their home or previous placement. • To develop foster environments capable of responding to the "whole child", including emotional and behavioral needs of neglected and abused children. • To provide education and support to foster parents. 4.5 Three (3), or more, specific outcomes of service: • Reduced effects of trauma on the child(ren) who have been removed from their home or previous placement. • Competent and confident foster parents capable of responding to the "whole child" including the • emotional and behavioral needs of neglected and abused children. • Foster parents with foundational knowledge regarding trauma, abuse and neglect, transitions, mental health system navigation, reunification, and baseline information about developmentally appropriate expectations and behaviors within the context of child welfare. 4.6 Target population of the service, including age and gender: Foster home households and families with children ages birth to 17 -years -old who are receiving co-occurring services (such as families with children in out -of -home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time) from the local department of Social Services or Kinship Caretakers English speaking participants and families, unless interpreter is provided by Weld County. 4.7 Languages service is available in (please list proficiency and if interpreter services are available): English 4.8 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: No 4.9 Service location — list where the service will take place (i.e. client's home, in -office, other) In office, home, or community. Rates Please Note: All rates need to include overhead and administrative work (i.e., scheduling or report writing). All rates should be per hour unless service is for evaluations/assessments, Home Studies or Monitored Sobriety. • For hourly Service rates please complete section 4.10 • For monthly Service rates please complete section 4.11 • For Home Study Providers please complete section 4.12 • For monitored Sobriety Providers please complete section 4.13 REV. OCT 2023 ATTACHMENT C - PROPOSAL 4.10 Hourly Service Rates: Service #4 Service Type $ Amount Unit Type 4.10a In-Office/Video 140 Per Hour 4.10b In -Home or Community 160 Per Hour 4.10c Service Transportation Provided with N/A Select Unit Type. 4.10d FTM, Staffing TDM, Prof. 100 per Hour 4.10e No show 120 per No Hour 4.10f Mileage rate 64 per Mile 4.11 Monthly Service Rates (each level must be listed): If applicable Service Name with Level 4.11a 4.11b 4.11c 4.11d 4.11e 4.11f 4.11g 4.11h 4.11i 4.11j Mileage rate is paid after 30 roundtrip miles. Rate per Month Minimum Hours of Service: { 4.12 Home Study Providers — List your rates in the box below. 4.13 Monitored Sobriety Providers — List your rates in the box below. Additional Comments 4.14 Weld County Use Only REV. OCT 2023 9 ATTACHMENT C - PROPOSAL Service Name: Program Area: Therapeutic Family Time _ife Skills Service #5 Scope of Work Please Note: If the service is a monthly package, different levels should be indicated. All monthly packages must state a specific minimum number of direct service hours. (Please address each line item below using bulleted points) 5.1 Modalities, curriculum, tools used in delivery of service (DO NOT list company history): • Strategic Therapy Principles • Psychoeducation • Therapeutic Games & Homework • Strength Based, Present -focused feedback • Incredible Years skills/principles (for parents of children 3-7 years old) 5.2 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: 2-4 hours per week 5.3 Anticipated duration of service (i.e. 3-4 months): 1-6 months; as necessary; as court ordered 5.4 Three (3), or more, specific goals of the service (DO use bullet points): • To provide a safe, welcoming environment to hasten the reunification process • To increase parent/child bonding • To increase knowledge of appropriate parenting skills and capability to provide for children's needs • To provide references and link families to additional services when necessary to meet children's special • physical and mental need • To provide therapeutic intervention and address barriers in parent/child relationship 5.5 Three (3), or more, specific outcomes of service: • Established, maintained or strengthened family relationships • Enhanced well-being of child(ren) and reduced trauma/effects of separation • Increased parenting skills and confidence to provide for children's needs • Barriers to parent/child relationship addressed/resolved 5.6 Target population of the service, including age and gender: Families with children ages birth to 18 -years -old who are receiving co-occurring services (such as families with children in out -of -home placement who are referred through the Family Courts to therapeutic intervention and facilitated Family Time) from the local department of Social Services or Kinship Caretakers English speaking participants and families, unless interpreter is provided by Weld County. 5.7 Languages service is available in (please list proficiency and if interpreter services are available): English 5.8 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Yes 5.9 Service location — list where the service will take place (i.e. client's home, in -office, other) In office, home, or community. Rates Please Note: All rates need to include overhead and administrative work (i.e., scheduling or report writing). All rates should be per hour unless service is for evaluations/assessments, Home Studies or Monitored Sobriety. • For hourly Service rates please complete section 5.10 • For monthly Service rates please complete section 5.11 • For Home Study Providers please complete section 5.12 • For monitored Sobriety Providers please complete section 5.13 5.10 Hourly Service Rates: REV. OCT 2023 10 ATTACHMENT C - PROPOSAL Service #5 Service Type $ Amount Unit Type 5.10a In-Office/Video 120 Per Hour 5.10b In -Home or Community 140 Per Hour 5.10c Service Transportation Provided with N/A Select Unit Type. 5.10d FTM, Staffing TDM, Prof. 100 per Hour 5.10e No show 120 per No Show 5.10f Mileage rate .64 per Mile 5.11 Monthly Service Rates (each level must be listed): If applicable Service Name with Level 5.11a 5.11b 5.11c 5.11d 5.11e 5.11f 5.11g 5.11h 5.11i 5.11j 5.12 Home Study Providers — List your rates in the box below. Mileage rate is paid after 30 roundtrip miles. Rate per Month Minimum Hours of Service: 5.13 Monitored Sobriety Providers — List your rates in the box below. Additional Comments 5.14 Weld County Use Only REV. OCT 2023 11 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. Provider Information Bidder's Legal Name: (As reflected on W-9) Sovereignty Counseling Services Number of services offered on this Attachment C (max 5): You may complete another Attachment Cif you have more than 5. 1 Service #1 Service Name: Program Area: Foster Parent Training Scope of Work Please Note: If the service is a monthly package, different levels should be indicated. All monthly packages must state a specific minimum number of direct service hours. (Please address each line item below using bulleted points) 1.1 Modalities, curriculum, tools used in delivery of service (DO NOT list company history): • Psychoeducation 1.2 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: 90-120 minutes/training 1.3 Anticipated duration of service (i.e. 3-4 months): 1-12 trainings per year 1.4 Three (3), or more, specific goals of the service (DO use bullet points): • Prepare/Support foster parents in providing nurturing care in a safe and healthy environment. • Prepare/Support foster parents in meeting the developmental and emotional needs of the children. • Develop skills in trauma informed parenting skills • Develop/Promote skills in protecting and promoting the child's cultural identity and heritage. • Develop/promote child's connection to his or her own family as appropriate. 1.5 Three (3), or more, specific outcomes of service: • Ongoing preparation and support for foster parents in meeting the needs of children who have been abused and neglected. Increased ability to address trauma response behaviors in foster children effectively and compassionately. • Competent and compassionate foster parents who provide care in a safe and healthy environments within Weld County. 1.6 Target population of the service, including age and gender: Prospective and current foster parents within the Department of Human Services in Weld County Colorado. 1.7 Languages service is available in (please list proficiency and if interpreter services are available): English 1.8 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: No 1.9 Service location — list where the service will take place (i.e. client's home, in -office, other) In Office, in Home Rates Please Note: All rates need to include overhead and administrative work (i.e., scheduling or report writing). All rates should be per hour unless service is for evaluations/assessments, Home Studies or Monitored Sobriety. • For hourly Service rates please complete section 1.10 • For monthly Service rates please complete section 1.11 • For Home Study Providers please complete section 1.12 REV. OCT 2023 1 ATTACHMENT C - PROPOSAL • For monitored Sobriety Providers please complete section 1.13 1.10 Hourly Service Rates: Service #1 Service Type $ Amount Unit Type 1.10a In-Office/Video 300 Per training 1.10b In -Home Community or 350 per training 1.10c Service Transportation Provided with N/A Select Unit Type. 1.10d FTM, Staffing TDM, Prof. N/A per Hour 1.10e No show 120 per No Show 1.10f Mileage rate .64 per Mile 1.11 Monthly Service Rates (each level must be listed): If applicable Service Name with Level Mileage rate is paid after Rate per Month 30 roundtrip miles. Minimum Hours of Service: 1.12 Home Study Providers — List your rates in the box below. List your rates in the box below. 1.13 Monitored Sobriety Providers Additional Comments 1.14 Weld County Use Only REV. OCT 2023 2 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: SOVEREIGNTY COUNSELING SERVICES Annette Leann Brown PHONE NUMBER: (970) 964-3133 EMAIL: info@sovereigntycounseling.com PROPOSED SERVICE(S): Individual Parent Training Therapy, Family Therapy, Kinship Consultation, Foster Parent Consultation, Therapeutic Family Time, Foster Legal Last Name Initial Middle Name Previous (If applicable) Legal Last Legal First Name Service Type Credentials Licensure/ DORA # (If applicable) Brown L Riedman Annette MA, LM FT MFT.0002021 All Williams Lindsey PHD, SWC SWC.0000000876 _ r-_ CHILD WELFARE REQUEST FOR PROPOSAL 2023-24 - VARIOUS SERVICES PSG 03/28/24 Sovereignty Counseling Services, PLLC 2580 E Harmony Rd Ste 201 Fort Collins, CO 80528-9632 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034-3278 Phone 1-888-288-3534 Fax 1-847-953-0134 Website www hpso corn Dear Annette Brown I Molly Enclosed is the replacement certificate of insurance that you requested If you have any questions or need assistance, please call us toll free at 1-888-288-3534 Our Customer Service Representatives are available weekdays from 8 00 a m to 6 00 p m , EST Sincerely, Customer Service Enclosure Dedicated 1 o Sefvfng The Intl once Needs of Healthcare P, ovidei s Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc (AR 244489), in CA 8 MN AIS Affinity Insurance Agency Inc (CA 0795465) in OK AIS Affinity Insurance Services Inc m CA Aon Affinity Insurance Services Inc (0G94493) Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY AIS Affinity Insurance Agency Q032 CNA HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP Certificate of Iii ttraitce OCCURRENCE PROFESSIONAL LIABILITY POLICY FORM OHPSO Print Date: 3/28/2024 The application for the Policy and any and allsupplementary information, materials, and statements submitted therewith shall be maintained on file by us or our Program Administrator and will be deemed attached to and incorporated into the Policy as if physically attached. PRODUCER BRANCH PREFIX POLICY NUMBER POLICY PERIOD From: 03/31/24 to 03/31/25 at 12:01 AM Standard Time 018098 970 HPG Named Insured and Address: 0684409943 Sovereignty Counseling Services, PLLC 2580 E Harmony Rd Ste 201 Fort Collins, CO 80528-9632 Medical Specialty: Code: Marriage/Family Counselor Firm 80723 Excludes Cosmetic Procedures Program Administered by: Healthcare Providers Service Organization 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034 1-888-288-3534 www. h pso. com Insurance Provided by: American Casualty Company of Reading, Pennsylvania 151 N. Franklin Street Chicago, IL 60606 Professional Liability $ 1,000,000 each claim $ 3,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability * Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection Defendant Expense Benefit Deposition Representation Assault Includes Workplace Violence Counseling Medical Payments First Aid Damage to the Property of Others Enterprise Privacy Protection - Claims Made Retroactive Date: 3/31/2020 (Defense inside limits) Media Expense Workplace Liability Workplace Liability Fire & Water Legal Liability Personal Liability Total $ 765.00 $ 25,000 per proceeding $ 25,000 aggregate $ 1,000 per day limit $ 25,000 aggregate $ 10,000 per deposition $ 10,000 aggregate $ 25,000 per incident $ 25,000 aggregate $ 25,000 $ 10,000 $ 10,000 $ 25,000 $ 25,000 per person per incident per incident per incident per incident $ 100,000 aggregate $ 10,000 aggregate $ 10,000 aggregate $ 25,000 aggregate $ 25,000 aggregate Included in Professional Liability Limit shown above Included in the PL limit shown above subject to $150,000 aggregate sublimit Excluded Base Premium $765.00 Policy Forms and Endorsements (Please see attached list of policy forms and endorsements) Chairman of the Board b 1. Secretary Keep this Certificate of Insurance in a safe place. It and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in full. To activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance. Coverage Change Date: Endorsement Date: CNA93692 (11-2018) © Copyright CNA All Rights Reserved. Master Policy: 188711433 POLICY FORMS & ENDORSEMENTS The following are the policy forms and endorsements that apply to your current professional liability policy. COMMON POLICY FORMS & ENDORSEMENTS FORM # G -121500-D (04-08) G -121503-C (07-01) G -121501-C (07-01) CNA94164 (11-18) G -145184-A (06-03) G -147292-A (03-04) GSL15564 (10-09) GSL15565 (03-10) GSL17101 (02-10) GSL13424 (05-09) GSL13425 (05-09) CNA80052 (09-14) G -123846-005 (07-01) Colorado Cancellation and Non -Renewal CNA81753 (03-15) Coverage & Cap on Losses from Certified Acts Terrorism CNA81758 (01-21) Notice - Offer of Terrorism Coverage & Disclosure of Premium CNA82011 (04-15) Related Claims Endorsement CNA79575 (07-14) Exclusion of Cosmetic Procedures CNA79516 (07-14) Enterprise Privacy Protection CNA89026 (05-17) Media Expense Coverage CNA96096 (06-19) Amended Definition of You and Yours G -141231-A (07-01) Additional Insured Healthcare Entity FORM NAME Common Policy Conditions Workplace Liability Form Occurrence Policy Form Amendment Definition of Claim Endorsement Policyholder Notice - OFAC Compliance Notice Policyholder Notice - Silica, Mold & Asbestos Disclosure Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion Healthcare Providers Professional Liability Assault Coverage Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies Services to Animals Business Owner Coverage Extension Endorsement Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax. As required by 806 Ky. Admin Regs. 2:100, this Notice is to advise you that a surcharge has been applied to your insurance premium and is separately itemized on the Declarations page or billing instrument attached to your policy, as required KRS. §136.392. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: Form #:CNA93692 (11-2018) Named Insured: Sovereignty Counseling Services, PLLC Master Policy #: 188711433 Policy #: 0684409943 ©Copyright CNA All Rights Reserved. SIGNATURE REQEUSTED: Weld/Sovereignty PSA Final Audit Report 2024-05-09 Created: 2024-05-08 By: Windy Luna (wluna@weld.gov) Status: Signed Transaction ID: CBJCHBCAABAASZ9Vw9QjIiHE5QkIURzURtpFQnevITGg "SIGNATURE REQEUSTED: Weld/Sovereignty PSA" History 5 Document created by Windy Luna (wluna@weld.gov) 2024-05-08 - 11:05:05 PM GMT- IP address: 204.133.39.9 El Document emailed to Annette Brown (annette@sovereigntycounseling.com) for signature 2024-05-08 - 11:05:59 PM GMT 5 Email viewed by Annette Brown (annette@sovereigntycounseling.com) 2024-05-09 - 1:05:21 AN GMT- IP address: 149.106.111.59 4 Document e -signed by Annette Brown (annette@sovereigntycounseling.com) Signature Date: 2024-05-09 - 1:06:44 AM GMT - Time Source: server- IP address: 149.106.111.59 © Agreement completed. 2024-05-09 - 1:06:44 AM GMT Powered by Adobe Acrobat Sign Contract Form Entity Information Entity Name* Entity ID SOVEREIGNTY COUNSELING @00042283 SERVICES PLLC Contract Name* SOVEREIGNTY COUNSELING SERVICES PLLC (NEW PROFESSIONAL SERVICES AGREEMENT RELATED TO BID #B2400040( Contract Status CTB REVIEW New Entity? Contract ID 8193 Contract Lead * WLUNA Contract Lead Email wluna@weldgov.com;cob bxxlk@weldgov.com Parent Contract ID Requires Board Approval YES Department Project # Contract Description* (CONSENT) SOVEREIGNTY COUNSELING SERVICES PLLC NEW PROFESSIONAL SERVICES AGREEMENT RELATED TO BID #B2400040. TERM: 06/01 /2024 THROUGH 05/31/2027. Contract Description 2 PROVIDER WAS LISTED ON APPROVED VENDOR LIST PRESENTED TO THE BOCC ON 04/10/24. Contract Type* AGREEMENT Amount* $0.00 Renewable* YES Automatic Renewal Grant IGA Department Requested BOCC Agenda Due Date HUMAN SERVICES Date* 05/18/2024 05/22/2024 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 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" 03/31/2025 Renewal Date" 06/01/2025 Committed Delivery Date Expiration Date Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date CONSENT 05/13/2024 Approval Process Department Head Finance Approver Legal Counsel JAMIE ULRICH CONSENT CONSENT DH Approved Date Finance Approved Date Legal Counsel Approved Date 05/13/2024 05/13/2024 05/13/2024 Final Approval BOCC Approved Tyler Ref # AG 052224 BOCC Signed Date Originator WLUNA BOCC Agenda Date 05/22/2024 Houstan Aragon From: Sent: To: Subject: noreply@weldgov.com Friday, April 4, 2025 1:36 PM CM-ClerktoBoard; Windy Luna; Lesley Cobb; CM-HumanServices-DeptHead Fast Tracked Contract ID (9316) Contract # 9316 has been Fast Tracked to CM -Contract Maintenance. You will be notified in the future based on the Contract information below: Entity Name: SOVEREIGNTY COUNSELING SERVICES PLLC Contract Name: SOVEREIGNTY COUNSELING SERVICES PLLC (NEW PROFESSIONAL SERVICES AGREEMENT RELATED TO BID #B2400040( Contract Amount: $0.00 Contract ID: 9316 Contract Lead: WLUNA Department: HUMAN SERVICES Review Date: 3/31/2027 Renewable Contract: NO Renew Date: Expiration Date:5/31/2027 Tyler Ref #: Thank -you Cor\-va6e` Da 93L0 Fa�'�vaCIC--12-Vt-Pv,fd 7074-4- 13 Z4 Houstan Aragon From: Sent: To: Cc: Subject: Sara Adams Friday, April 4, 2025 1:15 PM CTB HS -Contract Management FAST TRACK - Various Core Agreements (Tyler# Various) Good afternoon CTB, FAST TRACK ITEM: The below list will be Fast Track items in CMS for tracking purposes only to correct the expiration date. Contractor CMS # Tyler# New CMS# APPA THERAPY,'PLLC ASPEN COUNSELING, LLC BARTGES, ANGELA 8150 2023-1434 8141 2023-1393 8165 2023-1460 9292 9 9291 CASA OF LARIMER COUNTY COLORADO STATE UNIVERSITY 8176 2024-1270 9293 8286 2024-1518 9294 CREATIVE NURSING, LLC CROSSROADSX COUNSELING CRUX COUNSELING, LLC DEEP WATERS PARENTING 8151 2024-1221 8171 2024-1268 8132 9297 9298 2023-1396 9300 8734 2024-1264 KEEP SWIMMING,LLC KRAFT, DART 8750 2023-1438 8167 2023-1568 9302 MAISHA BORA LLC 8163 2024-1265 NEUROPSYC tOLC ICAL SOLUTIONS, LLC 8383 2024=1266 9304 NOCO SPEECH & DIAGNOSTICS NORTHERN HORIZON BEHAVIOI POLARIS PARTNERS LLC RABILLAR©, APRIL 8156 2023-1439 IEALTH 8187 2024-1319 8148 2023-1401 8397 2023=1569 9306 T, 9308 9 REACHING HOPE REECE, ALISON RHEGNUMI CONSULTING, LLC RIGHT,ON LEARNING SENSITIVE SOLUTIONS BEHAVIORAL HEALTH, LLC SEVIEfi, STACY.G. SIMPLE ASSENT, LLC SOVEREIGNTY COUNSELING SERVICES PLLC 8190 8170 8168 8204 8182 8528 8215 2024-1321 9310 473 9311 2024-1267 9312 0241325 9313 2024-1271 9314 1432 9315 2024-1416 8193 2024-1324 9323 X16 SPECIALTY COUNSELING & CONSULTING LLC HE HE INITIATI UNIVERSITY OF NORTHERN COLORADO WHICH WAY? LLP 8263 2024-1474 9317 8188 2024-1320 9318 8219 2024-1327 9319 8162 2023-1436 9320., WILLOW COLLECTIVE PLLC MI VUNGS PRAYER 8192 2024-1323 9321 9015 20234397 9322 Thank you, Sara COUNTY, CO Sara Adams Contract Administrative Coordinator Department of Human Services Desk: 970-400-6603 P.O. Box A, 315 N. 11th Ave., Greeley, CO 80632 0 O O Join Our Team Important: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. 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