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Home My WebLink About20221544.tiffnkit,a IBS I53 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND PERKLEN CENTER FOR PSYCHOTHERAPY This Agreement Amendment made and entered into X51 day of 1" l , , 2024 by and between the Board of Weld County Commissioners, on behalf of the Weldounty Department ofHuman Services, hereinafter referred to as the "Department", and Perklen Center for Psychotherapy, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Anger Management/Domestic Violence, Mental Health Services, and Sexual Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2022-1544, approved on June 6, 2022. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement was set to end on May 31, 2023. • The Original Agreement was amended on: • May 1, 2023 to extend the term date through May 31, 2024. • The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2022-1544. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement as of June 1, 2024: 1. Term This agreement is being renewed for the third and final year, for the period June 1, 2024 through May 31, 2025. • All other terms and conditions of the Original Agreement remain unchanged. Ct nWn- dam. 5/15/24 ee:643.46/69 .5/i5/a� 20zZ- 1511 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: BY: BOARD OF COUNTY COMMISSIONERS Jerk to the Boar. WELD COUNTY, COLORADO Deputy Kevin D. Ross, Chair NTRACTOR: MAY 1 5 2024 erklen Center for Psychotherapy 2619 West 11th Street, Suite #23 Greeley, Colorado 80634 (970) 353-8171 ,]oalie Goer Bey: Jodie Goter(May1,202417:17 M. J Jodie Goter, Executive Director May 1, 2024 Date: 2022-15N� SIGNATURE REQUESTED: Weld/Perklen Amendment #2 Final Audit Report 2024-05-01 Created: 2024-05-01 By: Windy Luna (wluna@weld.gov) Status: Signed Transaction ID: CBJCHBCAABAAoTgP9myLwz_JU3jn10XOsiGbRAUs75YI "SIGNATURE REQUESTED: Weld/Perklen Amendment #2" Hist ory 5 Document created by Windy Luna (wluna@weld.gov) 2024-05-01 - 5:31:52 PM GMT- IP address: 204.133.39.9 2. Document emailed to Kim Draughon (jgoter@perklen.org) for signature 2024-05-01 - 5:32:30 PM GMT 5 Email viewed by Kim Draughon (jgoter@perklen.org) 2024-05-01 - 11:16:13 PM GMT- IP address: 74.125.215.67 S j Signer Kim Draughon (jgoter@perklen.org) entered name at signing as Jodie Goter 2024-05-01 - 11:17:06 PM GMT- IP address: 71.229.222.119 4 Document e -signed by Jodie Goter (jgoter@perklen.org) Signature Date: 2024-05-01 - 11:17:08 PM GMT - Time Source: server- IP address: 71.229.222.119 0 Agreement completed. 2024-05-01 - 11:17:08 PM GMT Powered by Adobe Acrobat Sign Contract Form Entity Information Entity Name * PERKLEN INCORPORATED Entity ID* @00028680 Contract Name* PERKLEN INCORPORATED (PROFESSIONAL SERVICES AGREEMENT AMENDMENT #2. RELATED TO BID #B2200040) Contract Status CTB REVIEW Q New Entity? Contract ID 8153 Contract Lead * WLUNA Contract Lead Email wluna@weldgov.com;cob bxxlk@weldgov.com Parent Contract ID 20221544 Requires Board Approval YES Department Project # Contract Description * (CONSENT) PERKLEN INCORPORATED (PROFESSIONAL SERVICES AGREEMENT AMENDMENT #2. RELATED TO BID #B2200040). TERM: 6/1 /24 THROUGH 5/31 /25. Contract Description 2 PROVIDER WAS LISTED ON APPROVED VENDOR LIST PRESENTED TO THE BOCC ON ORIGINALLY ON 04/6/22, AND AMENDED 6/13/22. Contract Type* AMENDMENT Amount* $0.00 Renewable * NO Automatic Renewal Grant IGA Department Requested BOCC Agenda Due Date HUMAN SERVICES Date* 05/16/2024 05/20/2024 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 Committed Delivery Date Renewal Date Expiration Date* 05/31/2025 Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date CONSENT 05/09/2024 Approval Process Department Head Finance Approver Legal Counsel JAMIE ULRICH CONSENT CONSENT DH Approved Date Finance Approved Date Legal Counsel Approved Date 05/09/2024 05/09/2024 05/09/2024 Final Approval BOCC Approved Tyler Ref # AG 051524 BOCC Signed Date Originator WLUNA BOCC Agenda Date 05/15/2024 Con%ac� I t&9W icnanf 5/ 1/Z3 PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 28, 2023 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2022-23 Core/Non-Core Contracted Services B2200040 Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement Amendments for 2022-23 Core/Non-Core Contracted Services B2200040. The Department entered into Agreements with various Child Welfare Service Providers through the 2022-23 Request for Proposal (RFP), Bid Number: B2200040, identified as Tyler ID 2022-0410. These Agreements were issued for a period of three (3) years with the option to renew annually. The Department is requesting to renew the current Agreements with no changes for thirty-one (31) Providers reflected in the attached list. Agreements will be renewed for the second year, for the period of June 1, 2023 through May 31, 2024. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed Agreement Amendments will be obtained from Providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. I recommend approval of these Agreement Amendments and authorize the Chair to sign. Approve Recommendation Perry L. Buck, Pro -Tern Mike Freeman, Chair Scott K. James Kevin D. Ross Lori Saine Schedule Work Session Other/Comments: Pass -Around Memorandum; March 28, 2023 — CMS ID Various Page 1 C&I OtAeitea4t5P) n/I /&3 2022e15q 4 12009(-1 i PRIVILEGED AND CONFIDENTIAL Ariel Clinical 'ervicei 200040 2022-23 2022-1 Aver Ps chological & Wellness Services 82200040 2022-23 2022-1476 I: Brads House Centennial BOCES shrislt risen, David L DAYS Denver Area Youth Services B2200040 2022-23 2022-1539 Ebbinghaus, Krystal 82200040 4_022-23 2022-1464 Fi nn Counselin-, LLC B2200040 2022-23 i 2022-1466 200040 2022-23 2022-1537 B2200040 2022-23 2022-1471 Garcia Family Guidance Inc. IDEA Forum, Inc. Inspired Pathways Counselin: Services LLC Intervention, Inc. Jacob Famil Services, Inc. DBA The Jacob Center Lifestance Health B2200040 2022-2.3 B2200040 2022-23 2022-1813 82200040 2022-23 2022-1591 B2200040 2022-23 2022-1540 2200040 02200040 Lutheran Family Services Rocky Mountains 82200040 2022-23 12022-153 2022-23 12022-2674 202 232022-1468 LWGG^GJ . Martinez, Tim DBA Assurance Therapeutic Services, LTD B2200040 2022-23 2022-2398 North Range Behavioral Health Northern Colorado Youth for Christ 82200040 2022-23 2022-1546 02200040 2022-23 2022-1470 Parker Personal Care Homes, Inc. dba David ' Its j 82200040 2022-23 Perklen Center for Psychotherapy 2i 22-1 9`16 B2200040 2022-23 2022-1544 ioundtables Collaborations of Colorado (Rick Hartman) Scroggisis, Julie A Smith Agency 42200040 .2022-23 2022- B2200040 2022-23 2022-1533 82200040 2022-23 Specialized Alternatives for Families and Youth of Colorado, Inc. (SAFY) Strong Foundations, LLC I Swisher; Nathan Tennyso0 Center for Children Third Way Center Transitions Psydholo Grou., LLC Turning Point Center for Youth and Family Development, Inc. UABACO LLC 2-167, B2200040 2022-23 2022-1596 } 82200040 2022-23 2022-1597 B2200040 2022-23 22022-1474 62200040 2022-23 12022-1593 B2200040 2022-23 2022-1477 82200 2022-23 02200040 2022-23 B2200040 2022-2 2022-1542 2022-1475 2022-1728_ Pass -Around Memorandum; March 28, 2023 — CMS ID Various Page 2 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND PERKLEN CENTER FOR PSYCHOTHERAPY This Agreement Amendment, made and entered into Y da ofM 2023 bg 1St _ by and between the Board of Weld County Commissioners, on behalf of the Weld County Depa ent of Human Services, hereinafter referred to as the "Department", and Perklen Center for Psychotherapy, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Anger Management/Domestic Violence, Mental Health Services, and Sexual Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2022-1544, approved on June 6, 2022. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement will end on May 31, 2023. • This Amendment, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for the second year, for the period June 1, 2023 through May 31, 2024. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTES BY: 1 X11O;1A. COUNTY: BOARD OF COUNTY COMMISSIONERS C rk to the B • . r' WELD COUNTY, COLORADO Deputy Cle Mike Freeman, Chair MAY 0 1 2223 NTRACTOR: erklen Center for Psychotherapy 2619 West 11 to Street, Suite #23 Greeley, Colorado 80634 Jodie M. Goter By: Jodie M. Goter (Apr 17, 2023 13:09 MDT) Jodie Goter, Executive Director Apr 17, 2023 Date: ozoome- SIGNATURE REQUESTED: Weld/Perklen Amend #1 2023-24 Final Audit Report Status: Signed Transaction ID: CBJCHBCAAE3AAtcMHIjBuvHMe0NGu2HHMUmkDEl ys 2023-04-17 "SIGNATURE REQUESTED: Weld/Perklen Amend #1 2023-24" History IJ Document created by Windy Luna (wluna@co.weld.co.us) 2023-04-14 - 8:19:15 PM GMT -► Document emailed to Kim Draughon (jgoter@perklen.org) for signature 2023-04-14 - 8:25:45 PM GMT Email viewed by Kim Draughon (jgoter@perklen.org) 2023-04-17 - 5:59:45 PM GMT A. Signer Kim Draughon (jgoter@perklen.org) entered name at signing as Jodie M. toter 2023-04-17 - 7:09:15 PM GMT FSa Document e -signed by Jodie M. toter (jgoter@perklen.org) Signature Date: 2023-04-17 - 7:09:17 PM GMT - Time Source: server O Agreement completed. 2023-04-17 - 7:09:17 PM GMT Names and email addresses are entered into the Acrobat Sign service by Acrobat Sign users and are unverified unless otherwise noted. Powered by Adobe Acrobat Sigm Contract Form Entity Name* PERKLEN INCORPORATED ❑ New Entity? Entity ID* @00028680 Contract Name* PERKLEN CENTER FOR PSYCHOTHERAPY (CHILD PROTECTION AGREEMENT AMENDMENT #1) Contract Status CTB REVIEW Contract ID 6868 Contract Lead* WLUNA Contract Lead Email wluna@weldgov.com;cobbx na@weldgov.com;cobbx xlk@weldgov.com Parent Contract ID 20221544 Requires Board Approval YES Department Project # Contract Description* (CONSENT) PERLEN CENTER FOR PSYCHOTHERAPY (BID #B2200040) CHILD PROTECTION AGREEMENT AMENDMENT #1. TERM: 06/01/2023 THROUGH 05/31/2024. Contract Description 2 PROVIDER WAS LISTED ON APPROVED VENDOR UST PRESENTED TO THE BOCC ON 03/28/2023 AND AS A COMMUNICATION ITEM/PA SENT TO CTB ON 03/30/2023. Contract Type* AGREEMENT Amount* $0.00 Renewable. NO Automatic Renewal Grant Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.co Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEYOWELDG OV.COM Requested BOCC Agenda Date. 04/26/2023 Due Date 04/22/2023 Will a work session with 11OCC be required?* NO Does Contract require Purchasing Dept. to be induded? If this is a renewal enter previous Contract ID If this is part of a AEA 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 Effective Date Review Date* 03/29/2024 Renewal Date Termination Notice Period Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Approver Department Head JAMIE ULRICH DH Approved Date 04/18/2023 1f0CC Approved ®MCC Signed Date MCC Agenda Date 05/01/2023 Originator WLUNA Committed Delivery Date Finance Approver CHERYL PATTELLI Expiration Date* 05/31/2024 Purchasing Approved Date Finance Approved Date 04/18/2023 Tyler Ref it AG 050123 Legal Counsel BRUCE BARKER Legal Counsel Approved Date 04/19/2023 Con -Wad- fPt[58 O CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND PERKLEN CENTER FOR PSYCHOTHERAPY This Agreement, made and entered into the .9 day of ()Witt, , 2022, by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department" and Perklen Center for Psychotherapy, hereinafter referred to as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Scope of Services, Exhibit B, Rate Schedule, Exhibit C, Weld County's Request for Proposal, and Exhibit D, Contractor's Response to Request for Proposal. Exhibit A, B, and D are attached hereto and incorporated herein by this reference. Exhibit C is Weld County's Request for Proposal Number B220040 which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to the Department for Anger Management/Domestic Violence, Mental Health Services, and Sexual Abuse Treatment. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 2022, upon proper execution of this Agreement and shall expire May 31, 2023, unless sooner terminated as provided herein. This agreement may be renewed for 2 additional terms by written agreement of both parties. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit A Scope of Services, and Exhibit D, Contractor's Response to Request for Proposal. 3. Referrals, Billing and Tracking a. 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. b. 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. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Quality Assurance Team (HS-CWQualitvAssurance(aweldsov.com). No other Department staff or other party to the case may authorize services or modifications to services. c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation by the 7th of the month, following the month of service, utilizing billing forms required by the Department. Requests for Reimbursement Forms received after 45 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet 45 -day deadline may result in Conte+- Colo/OLQ/ZZ' cc' attat4bv &/10/0.20t. 2022-1544 () termination of the Agreement. d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service, for each client receiving ongoing services. 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. Date and time(s) of service (i.e. two hours or 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. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will be the test result. A completed home study may be a full, partial or denied study, as determined by the Department. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. 4. Payment a. 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: i. The service being provided by the contractor is not a Medicaid eligible service; ii. The service is not deemed medically necessary; iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; iv. A Medicaid provider is not available to provide the needed service; v. Medicaid is exhausted for the needed service; or vi. Medicaid denied service. vii. The client is not eligible for Medicaid. b. Payment shall be made in accordance with Exhibit A, Scope of Services , Exhibit B, Rate Schedule, Exhibit C, Weld County's Request for Proposal, and Exhibit D, Contractor's Response to Request for Proposal., attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. 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. d. 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. Financial Management 2 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. 6. Payment Method Unless otherwise provided in Exhibit A, Scope of Services, Exhibit B, Rate Schedule, and Exhibit D, Contractor's Proposal: a. If services are funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. b. 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. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and - Title VII of the Civil Rights Act of 1964; and the Age Discrimination in Employment Act of 1967; and - the Equal Pay Act of 1963; and - the Education Amendments of 1972; and Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and - all regulations applicable to these laws prohibiting discrimination because of race, color, national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions covered under Section 504 of the 3 Rehabilitation Act of 1973, as amended, cited above. If necessary, Contractor and the Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any all Federal and/or State financial assistance. - Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, contractors and sub -contractors. b. Contractor is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the United States Department of Health and Human Services, Office for Civil Rights. c. Contractor assures that it will fully comply with all other applicable Federal and State laws which may govern the ability of the Department to comply with the relevant funding requirements. Contractor understands the source of funds to be accessed under the Agreement is determined by the Department. d. Contractor assures and certifies that it and its principals: - Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a Federal or State department or agency; and - have not, within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; and are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state or local) with commission of any of the offenses enumerated in this certification; and - have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, or local) terminated for cause or default. e. Public Contracts for Services C.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this contract. Contractor will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E - Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5- 102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to undertake pre -employment screening or job applicants while this Agreement is being performed. If Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contractor shall not terminate the contract if within three days the subcontractor provides 4 information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. shall comply with reasonable requests made in the course of an investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and Employment. If Contractor participates in the State of Colorado program, Contractor shall, within twenty days after hiring a new employee to perform work under the contract, affirm that Contractor has examined the legal work status of such employee, retained file copies of the documents, and not altered or falsified the identification documents for such employees. Contractor shall deliver to the Department, a written notarized affirmation that it has examined the legal work status of such employee and shall comply with all of the other requirements of the State of Colorado program. If Contractor fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq., the Department, may terminate this Agreement for breach, and if so terminated, Contractor shall be liable for actual and consequential damages. f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if Contractor receives federal or state funds under the contract, Contractor must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the contract. If Contractor operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24- 76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. § 24-76.5- 103 prior to the effective date of the contract. 8. 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 3(d) of this Agreement. 9. Insurance Requirements Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Contractor shall provide the liability insurances (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged in the performance of this Agreement which are required under Weld County's Request for Proposal, and required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the acceptable evidence that such coverage is in effect prior to execution of this Agreement. At a minimum, Contractor shall procure, either personally or through its employer as applicable to the Contractor's business, at its own expense, and maintain for the duration of the work, insurance coverage listed in this agreement. The Board of County Commissioners of Weld County and its Officers/Employees shall be named as additional insured. 5 a. General Requirements: Contractors must secure, at or before the time of execution of any agreement or commencement of any work, the following insurance covering all operations, goods or services provided pursuant to this request. Contractors 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. The required insurance shall be underwritten by an insurer licensed to do business in Colorado and rated by A.M. Best Company as "A"VIII or better. Each policy shall contain a valid provision or endorsement stating "Should any of the above -described policies by canceled or should any coverage be reduced before the expiration date thereof, the issuing company shall send written notice to the Weld County Director of General Services by certified mail, return receipt requested. Such written notice shall be sent thirty (30) days prior to such cancellation or reduction unless due to non-payment of premiums for which notice shall be sent ten (10) days prior. If any policy is in excess of a deductible or self -insured retention, the Department must be notified by the Contractor. Contractor shall be responsible for the payment of any deductible or self -insured retention. The Department reserves the right to require Contractor to provide a bond, at no cost to the Department, in the amount of the deductible or self -insured retention to guarantee payment of claims. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. 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. b. Types of Insurance: Contractor shall obtain, and maintain at all times during the term of any Agreement, insurance in the following kinds and amounts: i.Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance covering all of Contractor's employees acting within the course and scope of their employment. If Contractor is an Independent Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93 or equivalent, covering premises operations, fire damage, independent Contractors, products and completed operations, blanket contractual liability, personal injury, and advertising liability with minimum limits as follows: - $1,000,000 each occurrence; - $2,000,000 general aggregate; - $50,000 any one fire; and - $500,000 errors and omissions. iii.Automobile Liability: 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. iv.Additional Provisions: Policies for all general liability, excess/umbrella liability, liquor liability and pollution liability must provide the following: - If any aggregate limit is reduced by twenty-five percent (25%) or more by paid or reserved claims, Contractor shall notify the Department within ten (10) days and reinstate the aggregates required; - Unlimited defense costs in excess of policy limits; - Contractual liability covering the indemnification provisions of this Agreement; - A severability of interests provision; - Waiver of exclusion for lawsuits by one insured against another; - A provision that coverage is primary; and - A provision that coverage is non-contributory with other coverage or self-insurance provided by the Department. v.For all general liability, excess/umbrella liability, liquor liability, pollution liability and professional liability policies, if the policy is a claims -made policy, the retroactive date must be on or before the contract date or the first date when any goods or services were provided to the Department, whichever is earlier. c. Contractors shall secure and deliver to County's Risk Administrator ("Administrator") at or before the time of execution of this Agreement, and shall keep in force at all times during the term of the Agreement as the same may be extended as herein provided, a commercial general liability insurance policy, including public liability and property damage, in form and company acceptable to and approved by said Administrator, covering all operations hereunder set forth in the related Bid or Request for Proposal. d. Proof of Insurance: Contractor shall provide a copy of this information to its insurance agent or broker and shall have its agent or broker provide proof of Contractor's required insurance. The Department reserves the right to require Contractor to provide a certificate of insurance, a policy, or other proof of insurance as required by the County's Risk Administrator in his sole discretion. e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal liability, liquor liability, and inland marine, Contractor's insurer shall name County as an additional insured. f. Waiver of Subrogation: For all coverages, Contractor's insurer shall waive subrogation rights against County. g. Subcontractors: All subcontractors, independent contractors, sub -vendors, suppliers or other entities providing goods or services required by this Agreement shall be subject to all of the requirements herein and shall procure and maintain the same coverages required of Contractor. Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers or other entities as insureds under its policies or shall ensure that all subcontractors maintain the required coverages. Contractor agrees to provide proof of insurance for all such subcontractors, independent contractors, sub -vendors, suppliers or other entities upon request by the Department. A provider of Professional Services shall provide the following coverage: Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and $2,000,000 aggregate limit for all claims. 10. 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. 11. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the 7 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. 13. 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 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. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. 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: - Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. - 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. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s). 8 For Department: For Contractor: Heather Walker, Child Welfare Division Head Jodie Goter, Executive Director 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich, Director P.O. Box A Greeley, CO 80632 (970) 400-6510 18. Litigation For Contractor: Jodie Goter, Executive Director 2619 West 1 lth Street, Suite #23 Greeley, Colorado 80634 (970) 353-8171 Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department, or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third -Party Beneficiary Enforcement 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. 21. Governmental Immunity No term or condition of this contract 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 of §§24-10-101 et. seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more 9 sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties/Conflict of Interest No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department when the Contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the two relationships are in opposition. During the term of the Agreement, Contractor shall not enter into any third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all 10 such information, in any form, including social networks. Contractor shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality requirements. Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County 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 from County as a result of the execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor. 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. Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, and as set forth in Exhibit C, provide proof thereof when requested to do so by County. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner consistent with the professional standards governing such services and the provisions of this Agreement. The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence 11 and judgment provided by highly competent individuals and entities that perform services of a similar nature to those described in this Agreement including Exhibits A, B, C, and D. 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to the Department originals of all tests and results, reports, and other similar items, generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. $$24-18-201 et seq. and &24-50-507 The signatories to this Agreement aver 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. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. 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. 34. 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. 35. Subcontractors Contractor acknowledges that the Department 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 this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 36. Attorney's Fees/Legal Costs 12 In the event of a dispute between the Department 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. 37. Ownership All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of the Department. 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 Department. Contractor shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of the Department. 38. 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. 39. 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. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: dia./WV W, si 0;CA By: BOARD OF COUNTY COMMISSIONERS ld County Clerk to th= Boar. WELL) COUNTY, COLORADO Deputy Cler ;/ o the Boar 13 Scott K. James, Chair CONTRACTOR: JUN 0 6 2022 Perklen Center for Psychotherapy 2619 West 11th Street, Suite #23 Greeley, Colorado 80634 (970)353-8171 (70d/ ' 41. Cote` By: Jodie M. Goter (May 24, 2022 16:11 MDT) Jodie Goter, Executive Director Date: May 24, 2022 acb2.2- /5W EXHIBIT A SCOPE OF SERVICES Contractor will provide Anger Management/Domestic Violence, Mental Health Services, and Sexual Abuse Treatment, as referred by the Department. Anger Management/Domestic Violence 1. Anger Management a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. A review of the client's available mental health records takes place in order for the clinician to determine the extent of the client's presenting problem and develop comprehensive treatment goals. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. ii. If warranted, the client will complete a mental health evaluation to aid in identifying the need for additional resources and referrals. The evaluation will consist of a social history interview, review of collateral data, and the administration of psychometric instruments. iii. Psychometric instruments may include the following: 1. The Hare Psychopathy Checklist -Revised. 2. Minnesota Multiphasic Personality Inventory -3. 3. Jesness Inventory. 4. Millon Clinical Multiaxial Inventory IV. 5. Shipley -2. 6. Beck Depression Inventory. 7. Beck Anxiety Inventory. 8. Dissociative Experiences Scale. iv. Individual and/or group counseling is beneficial for individuals dealing with anger management issues. v. Cognitive behavioral therapy will be the primary modality utilized to foster behavioral change. b. Anticipated Frequency of Services: i. Clients will meet weekly or bi-weekly for fifty (50) minute sessions until treatment goals are met. c. Anticipated Duration of Services: i. Typically, treatment lasts twelve (12) weeks. However, duration will be adjusted based on the needs of each case. d. Goals of Services: i. Provide a structured program and environment for the safety of the client, family, and community. ii. Increase awareness and empathy for family members, victims, and the community regarding the impact of crime. iii. Foster a family environment to effect positive change. iv. Develop the use of appropriate cognitive, social, and communication skills to reduce reactive and concerning behaviors. e. Outcomes of Services: i. Management of symptoms that have disrupted client's day-to-day activities. ii. Development and utilization of strategies to cope with symptoms and upsetting triggers. 1 iii. Strategies include journaling, mindfulness exercises, and stress management. f. Target Population: i. Ages twelve (12) and older. ii. Any gender. iii. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ). iv. Veteran and active service members. v. Victims of abuse and/or neglect. vi. Those with a history of incarceration and imprisonment. vii. Gang members. viii. Cult survivors. ix. Those with anger management issues. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -office. ii. Telehealth - Virtual sessions take place over the phone or video. 2. Domestic Violence Impact on Children and Victims Education a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. A four (4) hour education -based class solely to education individuals, family members, and concerned parties about the impact of domestic violence on children and victims who have been impacted by being in a home where domestic violence is prevalent. The cycle of violence, types of violence, how children and victims are traumatized by witnessing domestic violence, misconceptions about domestic violence, and trauma signs and symptoms are a part of the curriculum. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. b. Anticipated Frequency of Services: i. Clients will meet for two (2) sessions lasting for 2 hours each or four (4) sessions lasting for one (1) hour each. In some cases, additional sessions might be needed. The Client will be informed if additional time is needed. c. Anticipated Duration of Services: i. Four (4) hours over the total of two (2) sessions. d. Goals of Services: i. To teach clients how children, victims, and secondary victims are impacted by domestic violence. e. Outcomes of Services: i. Client will be able to discuss trauma symptoms. ii. Client will learn each stage of the cycle of abuse. iii. Client will be able to develop strategies for the prevention of trauma to children. f. Target Population: i. Ages twelve (12) and older. ii. Any gender. 2 iii. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ). iv. Veteran and active service members. v. Victims of abuse and/or neglect. vi. Those with a history of incarceration and imprisonment. vii. Gang members. viii. Cult survivors. ix. Those with anger management issues. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -office. ii. Telehealth - Virtual sessions take place over the phone or video. Mental Health Services 3. Mental Health Therapy a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. A review of the client's available mental health records takes place in order for the clinician to determine the extent of the client's presenting problem and develops comprehensive treatment goals. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. ii. In most cases, a Mental Health Evaluation will be completed with the client to assess for the presence of overt psychological concerns and to make specific treatment recommendations, if warranted. The evaluation can also aid in identifying the need for additional resources and referrals. The evaluation will consist of a social history interview, review of collateral data, and the administration of psychometric instruments. iii. The psychometric instruments used may include: 1. The Hare Psychopathy Checklist -Revised. 2. Minnesota Multiphasic Personality Inventory -3. 3. Jesness Inventory. 4. Millon Clinical Multiaxial Inventory IV. 5. Shipley -2. 6. Beck Depression Inventory. 7. Beck Anxiety Inventory. 8. Dissociative Experiences Scale. iv. Individual and/or group counseling is beneficial for individuals dealing with anger management issues. v. Cognitive behavioral therapy will be the primary modality utilized to foster behavioral change. b. Anticipated Frequency of Services: i. Clients will meet weekly or biweekly for fifty (50) minute sessions until treatment goals are met. c. Anticipated Duration of Services: i. Typically, treatment will last for four (4) to six (6) months. However, duration will be adjusted based on the needs of each case. 3 d. Goals of Services: i. To assist the client in decreasing symptoms presented at intake. ii. The client will develop self -management and self -regulation tools. iii. The client will be able to manage life symptom free. e. Outcomes of Services: i. Management of symptoms that have disrupted client's day-to-day activities. ii. Development and utilization of strategies to cope with symptoms and upsetting triggers. iii. Strategies include journaling, mindfulness exercises, and stress management. f. Target Population: i. Treatment for adults, juveniles, individuals with developmental/intellectual disabilities, and couples experiencing general mental health symptoms such as: 1. Dissociative behaviors. 2. Heightened anxiety. 3. Depressive symptoms. 4. Social and developmental patterns. 5. Potential for alcohol or substance abuse. 6. Developmental/intellectual disabilities. 7. Struggling with general life circumstances and transitions. 8. Grief 9. Sexual/pornography addictions. 10. Problematic sexual behavior. 11. Criminal/abusive behavior. 12. Anger. ii. Ages twelve (12) and older. iii. Any gender. iv. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ). v. Veteran and active service members. vi. Victims of abuse and/or neglect. vii. Those with a history of incarceration and imprisonment. viii. Gang members. ix. Cult survivors. x. Those with anger management issues. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -office. ii. Telehealth -Virtual sessions take place over the phone or video. 4. Mental Health Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Mental Health Evaluation will be completed with the client to assess for the presence of overt psychological concerns and to make specific treatment recommendations, if warranted. The evaluation will aid in identifying the need for additional resources and referrals. The evaluation will consist of a social history interview, review of collateral data, and the administration of psychometric instruments. ii. The psychometric instruments used will be appropriate for that specific population: adults, juveniles, and Developmentally Disabled (DD) / Intellectually Disabled (ID). 4 iii. In addition to determining the above noted factors, the evaluation will aid in identifying the need for additional resources and referrals. iv. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. b. Anticipated Frequency of Services: i. Clients will meet for two (2) sessions lasting for two (2) hours each. In some cases, additional sessions might be needed. The client will be informed if additional time is needed. Additional sessions are included in the cost of the evaluation. c. Anticipated Duration of Services: i. The full evaluation will be completed within a two (2) month period. d. Goals of Services: i. Determine treatment needs. ii. Determine unhealthy psychological, social, and developmental patterns. iii. Determine recommendations for treatment. e. Outcomes of Services: i. An evaluation will assist individuals in determining the symptoms that have disrupted their day-to-day activities. ii. Recommendation for treatment or adjunct services will be provided. As with most individuals suffering from mental health issues, weekly or biweekly treatment is recommended for a successful outcome. f. Target Population: i. Treatment for adults, juveniles, individuals with developmental/intellectual disabilities, and couples experiencing general mental health symptoms such as: 1. Dissociative behaviors. 2. Heightened anxiety. 3. Depressive symptoms. 4. Social and developmental patterns. 5. Potential for alcohol or substance abuse. 6. Developmental/intellectual disabilities. 7. Struggling with general life circumstances and transitions. 8. Grief. 9. Sexual/pornography addictions. 10. Problematic sexual behavior. 11. Criminal/abusive behavior. 12. Anger. ii. Ages twelve (12) and older. iii. Any gender. iv. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ). v. Veteran and active service members. vi. Victims of abuse and/or neglect. vii. Those with a history of incarceration and imprisonment. viii. Gang members. ix. Cult survivors. x. Those with anger management issues. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. 5 i. Service Access and Transportation: i. In -office ii. Telehealth -Virtual sessions take place over the phone or video. Sexual Abuse Treatment 5. Sex Offense Specific Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Offense specific evaluation for adults, juveniles, individuals with developmental/intellectual disabilities who have committed a sex offense. Evaluation is used to determine: 1. Client's amenability to sex offense -specific treatment. 2. Client's risk to re -offend violently and/or sexually. 3. The presence of overt psychological concerns. 4. Client specific treatment needs/goals. 5. Client specific responsivity factors. ii. Client's collateral information is reviewed such as mental health/psychological evaluations and records, Department of Human Services (DHS) reports, police reports, and victim statements. The evaluation will consist of a social history interview, review of collateral data, an Abel Assessment for Sexual Interest and the administration of psychometric instruments. The psychometric instruments used will be appropriate to the population: Adult, juveniles, and Developmentally Disabled (DD) / Intellectually Disabled (ID). In addition to determining the above noted factors, the evaluation can also aid in identifying the need for additional resources and referrals. iii. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. b. Anticipated Frequency of Services: i. Clients will meet for three (3) two (2) hour sessions or until the evaluation is complete. c. Anticipated Duration of Services: i. The evaluation will be completed within four (4) to six (6) weeks after the last completed appointment d. Goals of Services: i. To help guide the treatment goals and resources needed. e. Outcomes of Services: i. Completed evaluation. f. Target Population: i. Ages twelve (12) and older. ii. Any gender. iii. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ). iv. Youth and adults with involvement in the criminal justice system or DHS for sexually offensive behavior. g. Language: i. English. h. Medicaid Eligibility: 6 i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -office. ii. Telehealth - Virtual sessions take place over the phone or video. 6. Individual Sex Offense Specific Treatment a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Offense specific treatment for adults, juveniles, individuals with developmental/intellectual disabilities, and individuals who have committed a sex offense entails the following: 1. Responsibility/accountability. 2. Education around Illegal vs legal sexual behavior. 3. Understand the concept of consent. 4. Understanding family dynamics that may have contributed to abusive behavior. 5. Identifying thought processes that allow one to commit abusive acts. 6. Education around healthy relationships and sexuality. 7. Understanding the impact to primary, secondary, and tertiary victims. 8. Address deviant sexual behavior. 9. Educate on different forms of abuse. 10. Relapse prevention. 11. Learning to live a pro -social balanced life. 12. Setting short and long-term goals. ii. Therapy for adolescents and adult sexual abusers consists of a non -medical, cognitive behavioral model, which emphasizes a strengths -based approach. Studies have shown that caring confrontation (pointing out client errors in thinking and behavior while treating the client with respect) is the most effective way of motivating the client to make changes. This model also focuses on the various types of abuse that clients have committed in addition to their illegal/abusive sexual behavior, including physical, emotional, verbal and psychological. Understanding when sexual behavior is abusive will be taught by helping clients understand the concept of consent, victim empathy, responsibility, and relapse prevention. Treatment goals, type and frequency of services, and modality of delivery of services match a risk need responsivity model. iii. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. b. Anticipated Frequency of Services: i. Clients appropriate for individual sessions will meet one (1) time per week for a fifty (50) minute session. c. Anticipated Duration of Services: i. Treatment is open ended; only when the requirements for discharge as mandated by the Sex Offender Management Board (SOMB) are met will treatment end. d. Goals of Services: i. Client will be able to identify how children, victims, and secondary victims are impacted by sexual offending. ii. Client will be able to identify their cycle of behavior or chain of events and develop an intervention plan. iii. Client will decrease their risk for re -offense. e. Outcomes of Services: 7 i. Upon completion of the program, clients should be able to demonstrate the following: Consistently define all sexually abusive behavior, acknowledge risks by demonstrating foresight and use safety planning, consistently recognize/interrupt sexual abuse cycle, demonstrate new coping skills and develop stress management techniques, demonstrate victim empathy and understand how his/her behavior effects the victim, family, community, etc., display accurate attribution of responsibility for offending behavior, able to manage frustration and unfavorable events, reject sexually abusive thoughts as dissonant with self-image, demonstrate pro -social relationship skills, project positive self- image, demonstrate the ability to resolve conflict and make decisions, celebrate appropriate behavior and experience pro -social activities, delay gratification, communicate assertively, and develop family and/or community support systems. The client will have an adaptive sense of purpose and future. Interventions will address welfare specific needs. f. Target Population: i. Ages twelve (12) and older. ii. Any gender. iii. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ). iv. Youth and adults with involvement in the criminal justice system or DHS for sexually offensive behavior. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -office. ii. Telehealth - Virtual sessions take place over the phone or video. 7. Group Sex Offense Specific Treatment a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Offense specific treatment for adults, juveniles, individuals with developmental/intellectual disabilities, and individuals who have committed a sex offense entails the following: 1. Responsibility/accountability. 2. Education around Illegal vs legal sexual behavior. 3. Understand the concept of consent. 4. Understanding family dynamics that may have contributed to abusive behavior. 5. Identifying thought processes that allow one to commit abusive acts. 6. Education around healthy relationships and sexuality. 7. Understanding the impact to primary, secondary, and tertiary victims. 8. Address deviant sexual behavior. 9. Educate on different forms of abuse. 10. Relapse prevention. 11. Learning to live a pro -social balanced life. 12. Setting short and long-term goals. ii. Group therapy for adolescents and adult sexual abusers consists of a non -medical, cognitive behavioral model, which emphasizes a strengths -based approach. Studies have shown that caring confrontation (pointing out client errors in thinking and behavior while treating the client with respect) is the most effective way of motivating the client to make changes. This model also focuses on the various types of abuse that clients have committed in addition to their illegal sexual behavior, including physical, emotional, verbal and psychological. Understanding when sexual behavior is abusive will be taught 8 by helping clients understand the concept of consent, victim empathy, responsibility, and relapse prevention. Treatment goals type and frequency of services, and modality of delivery of services matched a risk need responsivity model. iii. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. b. Anticipated Frequency of Services: i. Clients appropriate for a group setting will attend one (1) one and a half (1.5) hour clinical group and one (1) one (1) hour education group weekly. c. Anticipated Duration of Services: i. Treatment is open ended; only when the requirements for discharge as mandated by the Sex Offender Management Board (SOMB) are met will treatment end. d. Goals of Services: i. Client will be able to identify how children, victims, and secondary victims are impacted by sexual offending. ii. Client will be able to identify their cycle of behavior or chain of events and develop an intervention plan. iii. Client will decrease their risk for re -offense. e. Outcomes of Services: i. Upon completion of the program, clients should be able to demonstrate the following: Consistently define all sexually abusive behavior, acknowledge risks by demonstrating foresight and use safety planning, consistently recognize/interrupt sexual abuse cycle, demonstrate new coping skills and develop stress management techniques, demonstrate victim empathy and understand how his/her behavior effects the victim, family, community, etc., display accurate attribution of responsibility for offending behavior, able to manage frustration and unfavorable events, reject sexually abusive thoughts as dissonant with self-image, demonstrate pro -social relationship skills, project positive self- image, demonstrate the ability to resolve conflict and make decisions, celebrate appropriate behavior and experience pro -social activities, delay gratification, communicate assertively, and develop family and/or community support systems. The client will have an adaptive sense of purpose and future. Interventions will address welfare specific needs. f. Target Population: i. Ages twelve (12) and older. ii. Any gender. iii. Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ). iv. Youth and adults with involvement in the criminal justice system or DHS for sexually offensive behavior. g. Language: i. English. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In -office. ii. Telehealth - Virtual sessions take place over the phone or video. 9 Terms 1. Contractor will respond to the Quality Assurance Team (HS-CWQualityAssurance(a,weldgov.com within three (3) business days regarding the ability to accept the received referral. 2. 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 Quality Assurance Team HS- CWQualityAssurance(aweldgov.com. 3. 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 D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharge the client from services. Contractor must inform the caseworker and the Quality Assurance Team HS-CWQualityAssurance(a,weldgov.com within three (3) days of when the client is placed on a behavioral plan or discharged. 4. 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 Quality Assurance Team HS-CWQualityAssurancenuu,weldgov.com immediately via email, to discuss service continuation. 5. 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. 6. 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 Quality Assurance Team HS-CWQualityAssurance(aweldsov.com immediately AND on the required monthly report. 7. 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. 8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals will be approved by a new referral signed by the Child Welfare Supervisor. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 10 9. 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 Quality Assurance Team, and the facilitator documents in the meeting notes the timeframe that the provider attended and when participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the meeting notes. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone or virtually, if approved by the Department. 10. On a monthly basis, the Contractor will notify the Quality Assurance Team HS- CWQualitvAssurance(aiweldgov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 11 EXHIBIT B RATE SCHEDULE 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 specific in Paragraph 2, below. 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. 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 Anger Management / Domestic Violence Anger Management Rate Unit Type Service Name $90.00 Hour In-officeNideo $90.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $45.00 Each No Show Domestic Violence Impact on Children and Victims Education Rate Unit Type Service Name $90.00 Hour In-officeNideo $90.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $45.00 Each No Show Mental Health Services Mental health Therapy Rate Unit Type Service Name $90.00 Hour In-officeNideo $90.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $45.00 Each No Show Mental Health Evaluation Rate Unit Type Service Name $1,100.00 Each In-office/Video; complete evaluation $90.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $100.00 Each No Show Sexual Abuse Treatment Sex Offense Specific Evaluation Rate I Unit Type I Service Name $1,300.00 Each In-officeNideo; complete evaluation $90.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $100.00 Each No Show Individual Sex Offense Specific Treatment Rate Unit Type Service Name $90.00 Hour In-officeNideo $90.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $45.00 Each No Show Group Sex Offense Specific Treatment Rate Unit Type Service Name $50.00 Hour In-officeNideo $90.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $25.00 Each No Show 3. Submittal of Vouchers 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 . 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. 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. For ongoing services, proof of services rendered shall be a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. When submitting a request for payment 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. Exhibit C WELD COUNTY'S REQUEST FOR PROPOSAL (Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon request to the Department.) This page is intentionally left blank Exhibit D Contractor's response to the Request for Proposal Exhibit D contains the following documents: • Attachment B — Provider Information Form (PIF) • Attachment C — Proposal • Attachment D — Staff Data Sheet • Certificate of Insurance (COI) ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES — PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION Perklen Center for Psychotherapy Agency Name: Jodie Goter Provider Contact Full Name: (970)353-8171 Primary Phone Number (10 -digit): Primary Contact Email: Jgoter@perklen.org Trails Provider ID (if known): Title: Executive Director Ext.: Fax Number (10 -digit): N/A Web Address: (970)353-0371 2619 W 11th Street Rd Ste #23 Greeley, CO 80634 Agency Location Address (Street, city, state, zip): Agency Mailing Address (Street, city, state, zip): Agency Type (pick one): Public Company 2619 W 11th Street Rd Ste #23 Greeley, CO 80634 Private Non -Profit Private for Profit Send Referrals for Service to: Jennifer Wuthrich Referral Contact Name: Referral Phone Number (10 -digit): (970)353-8171 Ext.: Title: Office Manager Email: office@perklen.org Billing Contact Jennifer Wuthrich Billing Contact Name: Billing Phone Number (10 -digit): (970)353-8171 Ext.: Title: Office Manager Email: office@perklen.org CERTIFICATION ' I certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the specifications it has so indicated in this bid form. I further affirm intention to enter into an agreement with Weld County, on behalf of the Weld County Department of Human Services, and comply with all requirements of the contract, if awarded. The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to accept Ithe bid, or part of a bid, that, in the opinion of the Board, is in the best interests of the Board and of the County of Weld, State of Colorado. The Board of Weld County Commissioners shall give preference to resident Weld County bidders in all cases where the bids are competitive in price and quality. WELD COUNTY IS EXEMPT FROM COLORADO SALES TAXES. THE CERTIFICATE OF EXEMPTION NUMBER IS #98-03551-0000. I Authorized Rep. Full Name: Jodie Goter Executive Director Title: Authorized Rep. Email: Jgoter@perklen.org (970)353-8171 Phone (10 -digit): Ext.: 2619 W 11th Street Rd #23 Greeley, CO 80634 Authorized Rep. Address (Street, city, state, zip): I Signature of Authorized Rep.: Jodie, Getek Date: 01/19/2022 REV. DECEMBER 2021 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Program Area: Program Areas are listed in column 1 of the table located in Item XI of the Request You may complete another Attachment C if you have more than 5. for Proposal starting on page 13. Perklen Inc., dba Perklen Center for Psychotherapy Anger Management/Domestic Violence Number of services offered on this Attachment C (max 5): 2 If Service 2.1a 2.1b 2.1c 2.1d 2.1e SECTION 2 - Service Name(s) and Information the service is a monthly package, please offer different levels. All monthly packages must state a specific minimum number of direct service hours. #1 Name: Anger Management Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Treatment for adults, juveniles, individuals with developmental/intellectual disabilities that are 12 and older experiencing symptoms such as: • Power and control • Difficulty regulating emotions • Mental Health concerns related to anger • Potential for alcohol or substance abuse • Criminal/abusive behavior First a review of the client's available mental health records takes place. At that point the clinician determines the extent of the client's presenting problem and develops comprehensive treatment goals. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. In most cases, the client will enter a 12 -week anger management program focusing on cognitive restructuring. If warranted, the client will also need to complete a mental health evaluation to aid in identifying the need for additional resources and referrals. The evaluation will consist of a social history interview, review of collateral data, and the administration of psychometric instruments. The psychometric instruments used may include the following: The Hare Psychopathy Checklist -Revised, Minnesota Multiphasic Personality Inventory -3, Jesness Inventory, Millon Clinical Multiaxial Inventory -IV, Shipley -2, Beck Depression Inventory, Beck Anxiety Inventory, and the Dissociative Experiences Scale. Individual and/or group counseling is beneficial for individuals dealing with anger management issues. Cognitive behavioral therapy will be the primary modality utilized to foster behavioral change. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: I Clients will meet weekly or biweekly for 50 -minute sessions until treatment goals are met. Anticipated duration of service (i.e. 3-4 months): In order to provide the best care, and to meet treatment goals, it is expected that treatment will last twelve weeks. However, every case is different, and the duration will be adjusted accordingly. Three (3), or more, specific goals of the service (DO use bullet points): • Provide a structured program and environment for the safety of the client, family, and community. • Increase awareness and empathy for family members, victims, and the community regarding the impact of crime. • Foster a family environment to effect positive change. • Develop the use of appropriate cognitive, social, and communication skills to reduce reactive and concerning behaviors. Three (3), or more, specific outcomes of service: REV. OCT 2021 1 ATTACHMENT C - PROPOSAL 2.1f Treatment will assist individuals in managing symptoms that have disrupted their day-to-day activities. Sessions will assist individuals in developing and utilizing strategies to cope with symptoms and upsetting triggers. As with most anger management sessions, journaling, mindfulness exercises, and stress management outside of the session is effective for a successful outcome for some. Target population of the service, including age and gender: Male, female, LGBTQ, and any gender identified with, ages 12 to 18; male, female, LGBTQ, and any gender identified with, over the age of 19; veteran and active service members; victims of abuse and/or neglect; history of incarceration and imprisonment, gang members; cult survivors; and those with anger management issues. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Medicaid is not available. 2.1i Service location — list where the service will take place (i.e. client's home, in -office, other) Service offered both in -office and telehealth (virtual sessions over the phone or video) Service #2 Name: Domestic Violence Impact on Children and Victims Education 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Education for adults, juveniles, individuals with developmental/intellectual disabilities, and individuals experiencing the impact of domestic violence such as: • Domestic violence • Trauma symptom_ s • Abuse • Neglect • Cognitive distortions • Disfuctional communication • Violence • Anger • Trauma to children • Child welfare This is a four (4) hour education -based class solely to education individuals, family members, and concerned parties about the impact of domestic violence on children and victims who have been impacted by being in a home where domestic violence is prevalent. The cycle of violence, types of violence, how children and victims are traumatized by witnessing domestic violence, misconceptions about domestic violence, and trauma signs and symptoms are a part of the curriculum. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. 2.2b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: Clients will meet for two (2) sessions lasting for 2 hours each or four (4) sessions lasting for 1 hour each. In some cases additional sessions might be needed. The Client will be informed if additional time is needed. 2.2c Anticipated duration of service (i.e. 3-4 months): In order to provide the best education, and to meet the goals of the curriculum we will meet with the client twice for two (2) hours each session or four (4) sessions for one (1) hour each session. In some cases additional sessions might be needed. The client will be informed if additional time is needed. 2.2d Three (3), or more, specific goals of the service (DO use bullet points): • Client will be able to identify how children, victims, and secondary victims are impacted by domestic violence. • Client will be able to discuss trauma symptoms. • Client learns each stage of the cycle of abuse. • Client is able to develop strategies for the prevention of trauma to children. 2.2e Three (3), or more, specific outcomes of service: The client will be able to identify how children, victims, and secondary victims are impacted by domestic violence. They will be able to discuss trauma symptoms, each stage of the cycle of abuse, cognitive distortions around the concept of REV. OCT 2021 2 ATTACHMENT C - PROPOSAL domestic violence, and be able to develop strategies for prevention of trauma to children. Interventions will address child welfare specific needs. 2.2f Target population of the service: Male, female, LGBTQ, and any gender identified with, ages 12 to 18; male, female, LGBTQ, and any gender identified with, over the age of 19; victims of abuse and or/neglect; history of incarceration and imprisonment; gang members; cult survivors; and those dealing with the impact of domestic violence (as outlined above). 2.2g 2.2h 2.2i Languages service is available in (please list proficiency and if interpreter services are available): English Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Medicaid is not available. Service location — list where the service will take place (i.e. client's home, in -office, other) Service offered both in -office and telehealth (virtual sessions over the phone or video) Service #3 Name: 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.3b 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: 2.3c Anticipated duration of service (i.e. 3-4 months): 2.3d Three (3), or more, specific goals of the service (DO use bullet points): 2.3e Three (3), or more, specific outcomes of service: 2.3f Target population of the service: 2.3g Languages service is available in (please list proficiency and if interpreter services are available): 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2.3i Service location — list where the service will take place (i.e. client's home, in -office, other) Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3), or more, specific goals of the service (DO use bullet points): 2.4e Three (3), or more, specific outcomes of service: 2.4f Target population of the service: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2.4i Service location — list where the service will take place (i.e. client's home, in -office, other) Service #5 Name: REV. OCT 2021 3 ATTACHMENT C - PROPOSAL 2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.5b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part 2.6i Service location — list where the service will take place (i.e. client's home, in -office, other) 3.1 3.2 3.3 3.4 3.5 Section 3 — Service Access and Transportation YES YES NO Will you charge Weld County for transporting clients or mileage? Check one: ■ @ NO Will you conduct services in a client's home or in the community? Check one: ■ 0 NO Miles Will you transport clients to and/or from services? Check one: ■ YES 15 How many miles are you willing to travel round trip? List a specific number of miles. 0 When you calculate mileage, what is your starting point address? We do not offer transportation SECTION 4 - SERVICE RATES All rates need to include administrative work (i.e. scheduling or report writing) and overhead. Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except for those listed above. • For hourly rates complete section(s) 4.1-4.5. • For monthly rates complete section 4.6. • For Home study providers complete section 4.7. • For monitored sobriety testing providers complete section 4.8. 4.1 Hourly Service #1 Name: Anger Management 4.1a In-Office/Video: 4.1b In -Office with Transportation: In -Home or Community: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate: $ Amount $90 N/A N/A $90 $45 N/A Unit Type per Hour per Hour per Hour per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included in rate: 0 0 This is paid after the miles listed above. miles miles 4.2 Hourly Service #2 Name: Domestic Violence Impact on Children and Victims Education 4.2a In-Office/Video: $ Amount $90 Unit Type per Hour REV. OCT 2021 4 ATTACHMENT C - PROPOSAL 4.2b In -Office with Transportation: N/A per Hour No. of roundtrip miles included in rate: 0 miles 4.2c In -Home or Community: N/A per Hour No. of roundtrip miles included in rate: 0 miles 4.2d FTM, TDM, Prof. Staffing: $90 per Hour 4.2e No show: $45 per No Show 4.2f Mileage rate: N/A per Mile This is paid after the miles listed above. 4.3 Hourly Service #3 Name: $ Amount Unit Type 4.3a In-Office/Video: per Hour 4.3b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles 4.3c In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.3d FTM, TDM, Prof. Staffing: per Hour 4.3e No show: per No Show 4.3f Mileage rate: per Mile This is paid after the miles listed above. 4.4 Hourly Service #4 Name: $ Amount Unit Type 4.4a In-Office/Video: per Hour 4.4b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.4c FTM, TDM, Prof. Staffing: per Hour 4.4d No show: per No Show 4.4e Mileage rate: per Mile This is paid after the miles listed above. 4.5 Hourly Service #5 Name: $ Amount Unit Type 4.5a In-Office/Video: per Hour 4.5b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles 4.5c In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.5d FTM, TDM, Prof. Staffing: per Hour 4.5e No show: per No Show 4.5f Mileage rate: per Mile This is paid after the miles listed above. 4.6 Monthly Service Rates (each level must be listed): Service Name with Level Rate per Month No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4.7 Home Study Providers - List your rates in the box below. 4.8 Monitored Sobriety Providers - List your rates in the box below. Provider special notes: REV. OCT 2021 s ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Program Area: Program Areas are listed in column 1 of the table located in Item XI of the Request You may complete another Attachment C if you have more than 5. for Proposal starting on page 13. Perklen Inc., dba Perklen Center for Psychotherapy Mental Health Services Number of services offered on this Attachment C (max 5): 2 If Service 2.1a 2.1b 2.1c 2.1d SECTION 2 - Service Name(s) and Information the service is a monthly package, please offer different levels. All monthly packages must state a specific minimum number of direct service hours. #1 Name: Mental Health Therapy Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Treatment for adults, juveniles, individuals with developmental/intellectual disabilities, and couples experiencing general mental health symptoms such as: • Dissociative behaviors • Heightened anxiety • Depressive symptoms • Social and developmental patterns • Potential for alcohol or substance abuse • Developmental/intellectual disabilities • Struggling with general life circumstances and transitions • Grief • Sexual/pornography addictions • Problematic sexual behavior • Criminal/abusive behavior • Anger First a review of the client's available mental health records takes place. At that point the clinician determines the extent of the client's presenting problem and develops comprehensive treatment goals. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. In most cases, a Mental Health Evaluation will be completed with the client to assess for the presence of overt psychological concerns and to make specific treatment recommendations, if warranted. The evaluation can also aid in identifying the need for additional resources and referrals. The evaluation will consist of a social history interview, review of collateral data, and the administration of psychometric instruments. The psychometric instruments used may include the following: The Hare Psychopathy Checklist -Revised, Minnesota Multiphasic Personality Inventory -3, Jesness Inventory, Millon Clinical Multiaxial Inventory -IV, Shipley -2, Beck Depression Inventory, Beck Anxiety Inventory, and the Dissociative Experiences Scale. Individual and/or group counseling is beneficial for individuals dealing with mental health issues. Cognitive behavioral therapy will be the primary modality utilized to foster behavioral change. 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: Clients will meet weekly or biweekly for 50 -minute sessions until treatment goals are met. Anticipated duration of service (i.e. 3-4 months): In order to provide the best care, and to meet treatment goals, it is expected that treatment will last from four to six months. However, every case is different, and the duration will be adjusted accordingly. Three (3), or more, specific goals of the service (DO use bullet points): REV. OCT 2021 1 ATTACHMENT C - PROPOSAL • To assist the client in decreasing symptoms presented at intake. • The client will develop self -management and self -regulation tools. • The client will be able to manage life symptom free. 2.1e 2.1f 2.1g Three (3), or more, specific outcomes of service: Treatment will assist individuals in managing symptoms that have disrupted their day-to-day activities. Sessions will assist individuals in developing and utilizing strategies to cope with symptoms and upsetting triggers. As with most mental health sessions, journaling, mindfulness exercises, and stress management outside of the session is effective for a successful outcome for some. Target population of the service, including age and gender: Male, female, LGBTQ, and any gender identified with, ages 12 to 18; male, female, LGBTQ, and any gender identified with, over the age of 19; veteran and active service members; victims of abuse and/or neglect; history of incarceration and imprisonment; gang members; cult survivors; and those with general mental health needs. Languages service is available in (please list proficiency and if interpreter services are available): English 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Medicaid is not available. 2.1i Service location — list where the service will take place (i.e. client's home, in -office, other) Service offered both in -office and telehealth (virtual sessions over the phone or video) Service #2 Name: Mental Health Evaluation 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Mental Health Evaluation for adults, juveniles, individuals with developmental/intellectual disabilities, and individuals experiencing general mental health symptoms such as: • Dissociative behaviors • Heightened anxiety • Depressive symptoms • Social and developmental patterns • Potential for alcohol or substance abuse • Developmental/intellectual disabilities • Struggling with general life circumstances and transitions • Grief • Sexual/pornography addictions • Anger • Criminal/abusive behavior In most cases, a Mental Health Evaluation will be completed with the client to assess for the presence of overt psychological concerns and to make specific treatment recommendations, if warranted. The evaluation can also aid in identifying the need for additional resources and referrals. The evaluation will consist of a social history interview, review of collateral data, and the administration of psychometric instruments. The psychometric instruments used will be appropriate to the population: Adult, juveniles, and DD/ID. In addition to determining the above noted factors, the evaluation can also aid in identifying the need for additional resources and referrals. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. 2.2b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: Clients will meet for two (2) sessions lasting for 2 hours each. In some cases additional sessions might be needed. The Client will be informed if additional time is needed. This will not impact the final cost of the evaluation. 2.2c Anticipated duration of service (i.e. 3-4 months): 2.2d In order to provide the best care, and to meet the goals of the evaluation we will meet with the client twice for two (2) hours each session. The full evaluation will be completed within a two (2) month period. In some cases additional time may be needed and the client will be advised of this. Three (3), or more, specific goals of the service (DO use bullet points): • Determine treatment needs REV. OCT 2021 2 ATTACHMENT C - PROPOSAL • Determine unhealthy psychological, social and developmental patterns • Determine recommendations for treatment 2.2e Three (3), or more, specific outcomes of service: An evaluation will assist individuals in determining the symptoms that have disrupted their day-to-day activities. A recommendation for treatment or adjunct services will be provided. As with most individuals suffering from mental health issues, weekly or biweekly treatment is recommended for a successful outcome. 2.2f Target population of the service: Male, female, LGBTQ and any gender identified with, ages 12 to 18; male, female, LGBTQ and any gender identified with, over the age of 19; victims of abuse and or/neglect; history of incarceration and imprisonment gang members; cult survivors; and those with general mental health needs (as outlined above). 2.2g Languages service is available in (please list proficiency and if interpreter services are available): English 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Medicaid is not available. 2.2i Service location — list where the service will take place (i.e. client's home, in -office, other) Service offered both in -office and telehealth (virtual sessions over the phone or video) Service #3 Name: 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.3b 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: 2.3c Anticipated duration of service (i.e. 3-4 months): 2.3d Three (3), or more, specific goals of the service (DO use bullet points): 2.3e Three (3), or more, specific outcomes of service: 2.3f Target population of the service: 2.3g Languages service is available in (please list proficiency and if interpreter services are available): 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2.3i Service location — list where the service will take place (i.e. client's home, in -office, other) Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3), or more, specific goals of the service (DO use bullet points): 2.4e Three (3), or more, specific outcomes of service: 2.4f Target population of the service: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: REV. OCT 2021 3 ATTACHMENT C - PROPOSAL 2.4i Service 2.5a Service location — list where the service will take place (i.e. client's home, in -office, other) #5 Name: Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.5b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part 2.6i Service location — list where the service will take place (i.e. client's home, in -office, other) 3.1 3.2 3.3 3.4 3.5 Section 3 — Service Access and Transportation YES YES NO Will you charge Weld County for transporting clients or mileage? Check one: ■ NO Will you conduct services in a client's home or in the community? Check one: ■ ►ii NO Miles Will you transport clients to and/or from services? Check one: I YES * How many miles are you willing to travel round trip? List a specific number of miles. 0 When you calculate mileage, what is your starting point address? We do not offer transportation SECTION 4 - SERVICE RATES All rates need to include administrative work (i.e. scheduling or report writing) and overhead. Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except for those listed above. • For hourly rates complete section(s) 4.1-4.5. • For monthly rates complete section 4.6. • For Home study providers complete section 4.7. • For monitored sobriety testing providers complete section 4.8. 4.1 Hourly Service #1 Name: 4.1a 4.1b 4.1c 4.1d 4.1e REV. OCT 2021 Mental Health Therapy In-Office/Video: In -Office with Transportation: In -Home or Community: FTM, TDM, Prof. Staffing: No show: Mileage rate: $ Amount $90 N/A N/A $90 $45 N/A Unit Type per Hour per Hour per Hour per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included in rate: 0 0 This is paid after the miles listed above. miles miles 4 ATTACHMENT C - PROPOSAL 4.2 Hourly Service #2 Name: Mental Health Evaluation $ Amount Unit Type 4.2a In-Office/Video: $1,100 per Hour 4.2b In -Office with Transportation: N/A per Hour No. of roundtrip miles included in rate: 0 miles 4.2c In -Home or Community: N/A per Hour No. of roundtrip miles included in rate: 0 miles 4.2d FTM, TOM, Prof. Staffing: $90 per Hour 4.2e No show: $100 per No Show 4.2f Mileage rate: N/A per Mile This is paid after the miles listed above. 4.3 Hourly Service #3 Name: $ Amount Unit Type 4.3a In-Office/Video: per Hour 4.3b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles 4.3c In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.3d FTM, TDM, Prof. Staffing: per Hour 4.3e No show: per No Show 4.3f Mileage rate: per Mile This is paid after the miles listed above. 4.4 Hourly Service #4 Name: $ Amount Unit Type 4.4a In-Office/Video: per Hour 4.4b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.4c FTM, TDM, Prof. Staffing: per Hour 4.4d No show: per No Show 4.4e Mileage rate: per Mile This is paid after the miles listed above. 4.5 Hourly Service #5 Name: $ Amount Unit Type 4.5a In-Office/Video: per Hour 4.5b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles 4.5c In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.5d FTM, TDM, Prof. Staffing: per Hour 4.5e No show: per No Show 4.5f Mileage rate: per Mile This is paid after the miles listed above. 4.6 Monthly Service Rates (each level must be listed): Service Name with Level Rate per Month No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4.7 Home Study Providers — List your rates in the box below. 4.8 Monitored Sobriety Providers — List your rates in the box below. REV. OCT 2021 5 ATTACHMENT C - PROPOSAL Provider special notes: Mental Health Evaluation is a service that requires 10 hours of work and is billed at a flat rate of $1,100. REV. OCT 2021 6 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Program Area: Program Areas are listed in column 1 of the table located in Item XI of the Request You may complete another Attachment C if you have more than 5. for Proposal starting on page 13. Perklen Inc., dba Perklen Center for Psychotherapy Sexual Abuse Treatment Number of services offered on this Attachment C (max 5): 3 If Service 2.1a 2.1b 2.1c 2.1d 2.1e 2.1f 2.1g 2.1h SECTION 2 - Service Name(s) and Information the service is a monthly package, please offer different levels. All monthly packages must state a specific minimum number of direct service hours. #1 Name: Sex Offense Specific Evaluation Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Offense specific evaluation for adults, juveniles, individuals with developmental/intellectual disabilities who have committed a sex offense. Evaluation is used to determine: Client's amenability to sex offense -specific treatment • Client's risk to re -offend violently and/or sexually • The presence of overt psychological concerns • Client specific treatment needs/goals • Client specific responsivity factors First client's collateral information is reviewed such as mental health/psychological evaluations and records, OHS reports, police reports, and victim statements. The evaluation will consist of a social history interview, review of collateral data, an Abel Assessment for Sexual Interest and the administration of psychometric instruments. The psychometric instruments used will be appropriate to the population: Adult, juveniles, and DD/ID. In addition to determining the above noted factors, the evaluation can also aid in identifying the need for additional resources and referrals. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. 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: Clients will meet for three (3) two (2) hour sessions or until the evaluation is complete. Anticipated duration of service (i.e. 3-4 months): The evaluation will be completed within four to six weeks after the last completed appointment Three (3), or more, specific goals of the service (DO use bullet points): rr r d r r d rr d Three (3), or more, specific outcomes of service: The evaluation will help guide the treatment goals and resources needed Target population of the service, including age and gender: Male, female, LGBTQ, and any gender identified with, ages 12 to 18; male, female, LGBTQ, and any gender identified with, over the age of 19, youth and adults with involvement in the criminal justice system or DHS for sexually offensive behavior. Languages service is available in (please list proficiency and if interpreter services are available): English Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Medicaid is not available. REV. OCT 2021 1 ATTACHMENT C - PROPOSAL 2.1i Service location — list where the service will take place (i.e. client's home, in -office, other) Service offered both in -office and telehealth (virtual sessions over the phone or video) Service #2 Name: Individual Sex Offense Specific Treatment 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Offense specific treatment for adults, juveniles, individuals with developmental/intellectual disabilities, and individuals who have committed a sex offense entails the following: • Responsibility/accountability • Education around Illegal vs legal sexual behavior • Understand the concept of consent • Understanding family dynamics that may have contributed to abusive behavior • Identifying thought processes that allow one to commit abusive acts • Education around healthy relationships and sexuality • Understanding the impact to primary, secondary, and tertiary victims • Address deviant sexual behavior • Educate on different forms of abuse • Relapse prevention • Learning to live a pro -social balanced life • Setting short and long-term goals Therapy for adolescents and adult sexual abusers consists of a non -medical, cognitive behavioral model, which emphasizes a strengths -based approach. Studies have shown that caring confrontation (pointing out client errors in thinking and behavior while treating the client with respect) is the most effective way of motivating the client to make changes. This model also focuses on the various types of abuse that clients have committed in addition to their illegal/abusive sexual behavior, including physical, emotional, verbal and psychological, Understanding when sexual behavior is abusive will be taught by helping clients understand the concept of consent, victim empathy, responsibility, and relapse prevention. Treatment goals, type and frequency of services, and modality of delivery of services match a risk need responsivity model. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered psychotherapist with oversight from a Licensed Professional Counselor. 2.2b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: Clients appropriate for individual sessions will meet once every week for a 50 minute session. 2.2c Anticipated duration of service (i.e. 3-4 months): Treatment is open ended; only when the requirements for discharge as mandated by the SOMB are met will treatment end. 2.2d Three (3), or more, specific goals of the service (DO use bullet points): • Client will be able to identify how children, victims, and secondary victims are impacted by sexual offending. • Client will be able to identify their cycle of behavior or chain of events and develop an intervention plan. • Client will decrease their risk for re -offense 2.2e Three (3), or more, specific outcomes of service: Upon completion of the program, clients should be able to demonstrate the following: Consistently define all sexually abusive behavior, acknowledge risks by demonstrating foresight and use safety planning, consistently recognize/interrupt sexual abuse cycle, demonstrate new coping skills and develop stress management techniques, demonstrate victim empathy and understand how his/her behavior effects the victim, family, community, etc., display accurate attribution of responsibility for offending behavior, able to manage frustration and unfavorable events, reject sexually abusive thoughts as dissonant with self-image, demonstrate pro -social relationship skills, project positive self-image, demonstrate the ability to resolve conflict and make decisions, celebrate appropriate behavior and experience pro -social activities, delay gratification, communicate assertively, and develop family and/or community support systems. The client will have an adaptive sense of purpose and future. Interventions will address welfare specific needs. 2.2f Target population of the service: REV. OCT 2021 2 ATTACHMENT C - PROPOSAL Male, female, LGBTQ, and any gender identified with, ages 12 to 18; male, female, LGBTQ and any gender identified with, over the age of 19, youth and adults who are involved in the criminal justice system or involved with DHS for sexually abusive behavior. 2.2g Languages service is available in (please list proficiency and if , services are available): English 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2.2i Medicaid is not available. Service location — list where the service will take place (i.e. client's home, in -office, other) Service offered both in -office and telehealth (virtual sessions over the phone or video) Service #3 Name: Group Sex Offense Specific Treatment 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Offense specific group treatment for adults, juveniles, individuals with developmental/intellectual disabilities, and individuals who have committed a sex offense entails the following: • Responsibility/accountability • Education around Illegal vs legal sexual behavior • Understand the -concept of consent • Understanding family dynamics that may have contributed to abusive behavior • Identifying thought processes that allow one to commit abusive acts • Education around healthy relationships and sexuality • Understanding the impact to primary, secondary, and tertiary victims • Address deviant sexual behavior • Educate on different forms of abuse • Relapse prevention • - Learning to live a pro -social balancedlife- • - Setting short and long-term goals Group therapy for adolescents and adult sexual abusers consists of a non -medical, cognitive behavioral model, which - emphasizes a strengths -based approach. Studies have shown that caring confrontation (pointing out client errors in thinking and behavior while treating the client with respect) is the most effective way of motivating the client to make changes. This model also focuses on the various types of abuse that clients have committed in addition to their illegal sexual behavior, including physical, emotional, verbal and psychological. Understanding when sexual behavior is abusive will be taught by helping clients understand the concept of consent, victim empathy, responsibility, and relapse prevention. Treatment goals type and frequency of services, and modality of delivery of services matched a risk need responsivity model. Services are provided by a Licensed Professional Counselor, a Licensed Professional Counselor Candidate or a registered. psychotherapist with oversight from a Licensed Professional Counselor. 2.3b 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: Clients appropriate for a group setting will attend one a 1.5 hour clinical group and one 1.0 hour education group weekly. 2.3c Anticipated duration of service (i.e. 3-4 months): 2.3d 2.3e Treatment is open ended; only when the requirements for discharge as mandated by the SOMB are met will treatment end. Three (3), or more, specific goals of the service (DO use bullet points): • Client will be able to identify how children, victims, and secondary victims are impacted by sexual offending. • Client will be able to identify their cycle of behavior or chain of events and develop an intervention plan. • Client will decrease their risk for re -offense Three (3), or more, specific outcomes of service: Upon completion of the program, clients should be able to demonstrate the following: Consistently define all sexually abusive behavior, acknowledge risks by demonstrating foresight and use safety planning, consistently recognize/interrupt sexual abuse cycle, demonstrate new coping skills and develop stress management techniques, demonstrate victim REV. OCT 2021 3 ATTACHMENT C - PROPOSAL empathy and understand how his/her behavior effects the victim, family, community, etc., display accurate attribution of responsibility for offending behavior, able to manage frustration and unfavorable events, reject sexually abusive thoughts as dissonant with self-image, demonstrate pro -social relationship skills, project positive self-image, demonstrate the ability to resolve conflict and make decisions, celebrate appropriate behavior and experience pro -social activities, delay gratification, communicate assertively, and develop family and/or community support systems. The client will have an adaptive sense of purpose and future. Interventions will address welfare specific needs. 2.3f Target population of the service: Male, female, LGBTQ, and any gender identified with, ages 12 to 18; male, female, LGBTQ, and any gender identified with, over the age of 19, youth and adults who are involved in the criminal justice system or involved with DHS for sexually abusive behavior. 2.3g Languages service is available in (please list proficiency and if interpreter services are available): English 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Medicaid is not available. 2.3i Service location — list where the service will take place (i.e. client's home, in -office, other) Service offered both in -office and telehealth (virtual sessions over the phone or video) Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3), or more, specific goals of the service (DO use bullet points): 2.4e Three (3), or more, specific outcomes of service: 2.4f Target population of the service: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2.4i Service location — list where the service will take place (i.e. client's home, in -office, other) Service #5 Name: 2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.5b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part REV. OCT 2021 4 ATTACHMENT C - PROPOSAL 2.6i Service location — list where the service will take place (i.e. client's home, in -office, other) Section 3 — Service Access and Transportation 3.1 Will you charge Weld County for transporting clients or mileage? Check one: 3.2 Will you conduct services in a client's home or in the community? Check one: 3.3 Will you transport clients to and/or from services? Check one: YES 3.4 How many miles are you willing to travel round trip? List a specific number of miles. 3.5 When you calculate mileage, what is your starting point address? YES NO YES NO NO 0 Miles We do not offer transportation SECTION 4 - SERVICE RATES All rates need to include administrative work (i.e. scheduling or report writing) and overhead. Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except for those listed above. • For hourly rates complete section(s) 4.1-4.5. • For monthly rates complete section 4.6. • For Home study providers complete section 4.7. • For monitored sobriety testing providers complete section 4.8. 4.1 Hourly Service #1 Name: Sex Offense Specific Evaluation 4.1a In-Office/Video: 4.1b In -Office with Transportation: In -Home or Community: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate: $ Amount Unit Type per Hour per Hour No. of roundtrip miles included in rate: per Hour No. of roundtrip miles included in rate: per Hour per No Show per Mile This is paid after the miles listed above. miles miles 1,300 N/A 0 N/A 0 $90 $100 N/A 4.2 Hourly Service #2 Name: Individual Sex Offense Specific Treatment 4.2a In-Office/Video: 4.2b In -Office with Transportation: 4.2c In -Home or Community: 4.2d FTM, TDM, Prof. Staffing: 4.2e No show: 4.2f Mileage rate: $ Amount Unit Type per Hour per Hour No. of roundtrip miles included in rate: per Hour No. of roundtrip miles included in rate: per Hour per No Show per Mile This is paid after the miles listed above. miles miles $90 N/A 0 N/A 0 $90 $45 N/A 4.3 Hourly Service #3 Name: Group Sex Offense Specific Treatment 4.3a In-Office/Video: 4.3b In -Office with Transportation: 4.3c In -Home or Community: 4.3d FTM, TDM, Prof. Staffing: 4.3e No show: 4.3f Mileage rate: $ Amount Unit Type per Hour per Hour No. of roundtrip miles included in rate: per Hour No. of roundtrip miles included in rate: per Hour per No Show per Mile This is paid after the miles listed above. miles miles $50 NA 0 N/A 0 $90 $25 N/A 4.4 Hourly Service #4 Name: $ Amount Unit Type REV. OCT 2021 5 ATTACHMENT C - PROPOSAL 4.4a In-Office/Video: per Hour 4.4b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.4c FTM, TDM, Prof. Staffing: per Hour 4.4d No show: per No Show 4.4e Mileage rate: per Mile This is paid after the miles listed above. 4.5 Hourly Service #5 Name: $ Amount Unit Type 4.5a In-Office/Video: per Hour 4.5b In -Office with Transportation: per Hour No. of roundtrip miles included in rate: miles 4.5c In -Home or Community: per Hour No. of roundtrip miles included in rate: miles 4.5d FTM, TDM, Prof. Staffing: per Hour 4.5e No show: per No Show 4.5f Mileage rate: per Mile This is paid after the miles listed above. 4.6 Monthly Service Rates (each level must be listed): Service Name with Level Rate per Month No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4.7 Home Study Providers — List your rates in the box below. 4.8 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: Sex Offense -Specific Evaluation is billed as a flat fee of $1,300 REV. OCT 2021 6 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:Jennifer Wuthrich Perklen Inc. PHONE NUMBER:(970)353-8171 EMAIL:office@perklen.org PROPOSED SERVICE(S): Mental Health, Domestic Violence Impact Education, 'Anger Management, and. Sex Offender Treatment for juvenile and adult offenders Goter M Jodie All proposed LPC#3138 ORA #.(If applicable) Galbreath L Tessa All proposed LPCC #19022 Kenigsberg M Cristina All proposed LPCC #19151 CHILD WELFARE REQUEST FOR PROPOSAL 2022-23 - VARIOUS SERVICES / ACORD® CERTIFICATE OF LIABILITY INSURANCE `..---- DATE (MM/DD/YYYY) 04/01/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Anderson -Ban Insurance, Inc. 7505 Village Square Drive, #203 Castle Rock CO 80108 CONTACT NAME: Richard Ban PHONE , e:tl; 303-322-2860 I jac, No): 303-322-6409 ADDARESS: andersonban@hotmail.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Lloyd's of London INSURED Perklen Inc dba Perklen Center for Psychotherapy 2619 W 11th Street Road Suite 23,25,13 Greeley CO 80634 INSURER B : Houston Casualty Ins Co INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/OD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY x x 11331131 4/1/2021 4/1/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 X CLAIMS -MADE OCCUR MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PRO- JECT PER: LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A B Professional liability Cyber Liability ($7,500 Deductible) x x x x 11331131 H2ONGP200312003 4/1/2021 4/1/2021 4/1/2022 4/1/2022 Occ $1,000,000 Occ $1,000,000 Agg $3,000,000 Agg $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Additional Insured: Board of County Commissioners of Weld County and its Officers/Employees on the GUPL Policy CERTIFICATE HOLDER CANCELLATION Weld County 1150OST Greeley, CO 80631 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (7.1,4?„„o ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Contract Form New Contract Request Entity Information Entity Name* PERKLEN INCORPORATED Entity ID* x00028680 Contract Name* PERKLEN CENTER FOR PSYCOTHERAPY (NEW CHILD PROTECTION AGREEMENT) Contract Status CTB REVIEW ❑ New Entity? Contract ID 5880 Contract Lead* APEGG Contract Lead Email apeggkgweldgov.corn cobbx xlkgvweldgov.com Contract Description* CONSENT BID# B2200040 TERM: JUNE 1, 2022 THROUGH MAY 31, 2023 Contract Description 2 PROVIDER WAS LISTED ON ITEM i PA SENT TO CTB ON Contract Type* AGREEMENT Amount * $ 0.00 Renewable* YES Automatic Renewal Grant IGA Parent Contract ID 20220410 Requires Board Approval YES Department Project I APPROVED VENDOR LIST PRESNETED TO THE BOCC ON 04:06:22 AND AS A COMMUNICATION 05#102022. Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.co m Department Head Email CM -Hu manServices- DeptHeada weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM - C OU NTYATTO RN EY1TWELDG OV,COM Requested BOCC Agenda Date* 06,'08: 2022 Due Date 06104'2022 Will a work session with 8OCC 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 On Base Contract Dates Date Termination Notice Period Contact Information Purchasing Purchas.ir CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 05'26,2022 BOCC Approved BOCC Signed Date BOCC Agenda Date 06'0612022 Originator APEGG Review Date * 03,31;2023 Committed Delivery Date Finance Approver CONSENT Renewal Date* 05/3112023 Expiration Date Contact Phone I Contact Phone 2 Purchasing 05'26,`2022' d Date Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 05/26/2022 Tyler Ref # AG 060622 05 26,'2022 Hello