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Home My WebLink About20231435.tiffCo c-Hgi9t0Z. BOARD OF COUNTY COMMISSIONERS PASS -AROUND REVIEW PASS -AROUND TITLE: Professional Services Agreement Amendment #2 with Jeremy T. Sharp, Ph.D., LLC dba Colorado Center for Assessment & Counseling DEPARTMENT: Human Services DATE: September 9, 2025 PERSON REQUESTING: Jamie Ulrich, Director, Human Services Brief description of the problem/issue: On May 22, 2023, the Department entered into a Professional Services Agreement with Jeremy T. Sharp, Ph.D., LLC dba Colorado Center for Assessment & Counseling, known to the Board as Tyler ID# 2023-1435 and is associated with the Request for Bid (RFB) #82300040. On May 15, 2024, Amendment #1 was executed to extend the term through May 31, 2026. The Department is now requesting approval of Amendment #2 to the Professional Services Agreement. This amendment updates Exhibit A, Scope of Services, and Exhibit B, Rate Schedule, to remove the Group Psychotherapy service and rate, and update rates for all services except mileage and Neuropsychological Evaluations, effective August 1, 2025. What options exist for the Board? • Approval of Amendment #2 with Jeremy T. Sharp, Ph.D., LLC dba Colorado Center for Assessment & Counseling. • Deny approval of Amendment #2 with Jeremy T. Sharp, Ph.D., LLC dba Colorado Center for Assessment & Counseling. Consequences: The Department will not enter into an amendment to update services and rates. Impacts: Provider may not provide needed services to Department of Human Services clients. Costs (Current Fiscal Year / Ongoing or Subsequent Fiscal Years): Fees for Services Program Area Rate Type Service Name Mental Health Services $175.00 Hour Individual/ Family Psychotherapy: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $175.00 Hour Individual/ Family Psychotherapy: In -Home or Community $175.00 Hour Individual/ Family Psychotherapy: In- OfficeNideo $0.65 Mile Individual/ Family Psychotherapy: Mileage exceeding 60 roundtrip miles from 3500 John D. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. Pass -Around Memorandum; September 9, 2025 - CMS ID 9902 Cbnsex Cb- CC Ohba (Dk+3) 9/Zz25 °t/ZZ/25 2.0Z3-1435 t-}12oo`I5 Program Area Rate $150.00 Type Each Service Name Individual! Family Psychotherapy: No Show (Max of 2 no shows or 2 hours/month/client) $200.00 Hour Neuropsychological Evaluation: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $225.00 Hour Neuropsychological Evaluation: In -Home! Community Mental Health Services $200.00 Hour Neuropsychological Evaluation: In-Office/Video $0.65 Mile Neuropsychological Evaluation: Mileage exceeding 120 roundtrip miles from 3500 John D. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. $200.00 Each Neuropsychological Evaluation: No Show (Max of 2 no shows or 2 hours/month/client) • Funded through Core/Non-Core Child Welfare funding. Recommendation: • Approval of Amendment #2 with Jeremy T. Sharp, Ph.D., LLC dba Colorado Center for Assessment & Counseling and authorize the Chair to sign. Support Recommendation Schedule Place on BOCC Mends Work Session Other/Comments: Perry L. Buck Scott K. James Jason S. Maxey Lynette Peppier Kevin D. Ross VarnaA. Vi ema Pass -Around Memorandum; September 9, 2025 - CMS ID 9902 Karla Ford From: Sent: To: Subject: Approve Kevin Ross Kevin Ross Wednesday, September 10, 2025 9:21 AM Karla Ford Re: Please Reply - PA FOR ROUTING: Jeremy Sharp dba Colo Ctr fo Assmt & Counseling Amendment #2 (CMS 9902) From: Karla Ford <kford@weld.gov> Sent: Wednesday, September 10, 2025 8:19:41 AM To: Kevin Ross <kross@weld.gov> Subject: Please Reply - PA FOR ROUTING: Jeremy Sharp dba Colo Ctr for Assmt & Counseling Amendn- ent #2 (CMS 9902) Please advise if you support recommendation and to have department place on the agenda. „sett__ J COUNTY, CO Karla Ford Office Manager & Executive Assistant Board of Weld County Commissioners Desk: 970-400-4200/970-400-4228 P.O. Box 758, 1150 0 St., Greeley, CO 80632 0 Join Our Team IMPORTANT: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Lesley Cobb <cobbxxlk@weld.gov> Sent: Tuesday, September 9, 2025 11:47 AM To: Karla Ford <kford@weld.gov> Cc: Bruce Barker <bbarker@weld.gov>; Cheryl Pattelli <cpattelli@weld.gov>; Chris D'Ovidio <cdovidio@weld.gov>; Rusty Williams <rwilliams@weld.gov>; Esther Gesick <egesick@weld.gov>; Jill Scott <jscott@weld.gov>; Lennie Bottorff <bottorll@weld.gov>; Tanya Geiser <tgeiser@weld.gov>; HS -Contract Management <HS - 1 Karla Ford From: Sent: To: Subject: Jason Maxey Tuesday, September 9, 2025 11:29 PM Karla Ford; Scott James Re: Please Reply - PA FOR ROUTING: Jeremy Sharp dba Colo Ctr for Assmt & Counseling Amendment #2 (CMS 9902) Approve. Thank you, Jason S. Maxey Weld Commissioner, District 1 Get Qutlook for 1QSS From: Karla Ford <kford@weld.gov> Sent: Tuesday, September 9, 2025 11:00:26 AM To: Scott James <sjames@weld.gov>; Jason Maxey <jmaxey@weld.gov> Subject: Please Reply - PA FOR ROUTING: Jeremy Sharp dba Colo Ctr for Assmt & Counseling Amendment #2 (CMS 9902) Please advise if you support recommendation and to have department place on the agenda. COUNTY, CO Karla Ford Office Manager & Executive Assistant Board of Weld County Commissioners Desk: 970-400-4200/970-400-4228 P.O. Box 758, 1150 0 St., Greeley, CO 80632 0 121 Join Our Team IMPORTANT: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 1 AGREEMENT AMENDMENT BETWEEN WELD COUNTY AND JEREMY T. SHARP, PHD, LLC DBA COLORADO CENTER FOR ASSESSMENT & COUNSELING This Agreement Amendment made and entered into day of 2025 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 Jeremy T. Sharp, Ph.D., LLC dba Colorado Center for Assessment & Counseling, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement to Mental Health Services, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2023-1435, approved on May 22, 2023. 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, 2024. • The Original Agreement was amended on: • May 15, 2024 to extend the term date through May 31, 2026. • The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2023-1435. 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 effective August 1, 2025: 1. Exhibit A, Scope of Services, is hereby amended as attached. 2. Exhibit B, Rate Schedule, is hereby amended as attached. 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. COUNTY: ATTEST:dJel" BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO BY: Clerk to the Board Deputy Clerk to the Buck, Chair SEP 2 2 2025 remy T. Sharp, Ph.D., LLC dba Colorado Center for Assessment & Counseling 3500 John F. Kennedy Parkway, Suite 200 Fort ollins, Colorquip 80525 By: Jeremy Sharp ( p 1, 2025 08:581:19 MDT) Jeremy T. Sharp, Ph.D. Director and Licensed Psychologist Date: 09/01/2025 2023-1435 EXHIBIT A SCOPE OF SERVICES Contractor will provide Mental Health Services, as referred by the Department. 1. Individual/Family Psychotherapy a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Psychotherapy will utilize modalities that include, but are not limited to: 1. Cognitive Behavioral Therapy (CBT). 2. Dialectical Behavior Therapy (DBT). 3. Mindfulness -based services. 4. Interpersonal therapy. 5. Exposure with response prevention. 6. Eye Movement Desensitization and Reprocessing (EMDR). b. Anticipated Frequency of Services: i. Initial session, sixty (60) minutes in duration. ii. Following sessions, thirty (30) to sixty (60) minutes, depending on client severity and needs. c. Anticipated Duration of Services: i. Varies depending on goal of the group and intensity of the presenting problem. ii. Sessions can occur multiple times weekly, bi-weekly, or monthly, depending on the client's severity and needs. d. Goals of Services: i. Provide quality. ethical services, as requested by the Department, in order to support Department staff and clients with mental health needs. e. Outcomes of Services: i. Improved mental health in various capacities. f. Target Population: i. Children ages five (5) to seventeen (17). ii. Adults of all ages. iii. Any gender. iv. Clients with a variety of presenting concerns and diagnoses. g. Language: i. English h. Medicaid Eligibility: i. This service is Medicaid eligible. i. Service Access and Transportation: i. In office located at 3500 John F. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. ii. Telehealth. 2. Neuropsychological Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Assessment will utilize standard measures including, but not limited, to the following tests: 1. Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-5). 2. Wechsler Intelligence Scale for Children® Fifth Edition (WISC-V). 3. Wechsler Individual Achievement Test, Third Edition (WIAT-4). 4. Kaufman Test of Educational Achievement 3rd Edition (KTEA-3). 5. Comprehensive Test of Phonological Processing 2 (CTOPP-2). 6. California Verbal Learning Test® Children's Version (CVLT-C). 7. CVLT-3. 8. ChAMP 9. Rey—Osterrieth Complex Figure (RCFT). 10. Conners Continuous Performance Test 3rd Edition (CCPT3). 11. Conners Kiddie Continuous Performance Test 2nd Edition (KCPT-2). 12.Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). 13. Behavior Assessment System for Children, Third Edition (BASC-3). 14. Behavior Rating Inventory of Executive Function, Second Edition (BRIEF -2). 15. Social Responsiveness Scale, Second Edition (SRS -2). 16. Adaptive Behavior Assessment System Third Edition (ABAS-3). b. Anticipated Frequency of Services: i. Initial interview, two (2) hours. ii. Testing, four (4) to six (6) hours. iii. Final feedback session, one (1) hour. c. Anticipated Duration of Services: i. Three (3) to four (4), appointments. ii. Three (3) to six (6), weeks, duration. d. Goals of Services: i. Provide comprehensive, strengths -based recommendations. ii. Facilitate growth, progress, and meet the requested outcomes. e. Outcomes of Services: i. Match both client and Department's needs. ii. Diagnostic clarity. iii. Appropriate treatment recommendations. iv. Facilitation of referral connections. f. Target Population: i. Children ages two and a half (2'/z) to seventeen (17). ii. Adults eighteen (18) and older. iii. Any gender. iv. Any sexual orientation. g. Language: i. English. ii. Spanish interpreter services available. h. Medicaid Eligibility: i. This service is Medicaid eligible. Service Access and Transportation: i. In office located at 3500 John F. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. ii. Telehealth. Terms 1. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. 2. Contractor agrees to receive referrals for services through e-mail and will provide an identified e-mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. 3. Contractor will respond to the Mental Health and Support Services Team (HS- CWServiceReferralaweldgov.com) within three (3) business days regarding the ability to accept the received referral. 4. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Mental Health and Support Services Team HS- CWServiceReferral weldgov.com. 5. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Mental Health and Support Services Team HS- CWServiceReferralCcilweldgov.com. No other Department staff or other party to the case may authorize services or modifications to services. 6. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit B, Rate Schedule, then Contractor understands that the Department will not reimburse for "no-shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharge the client from services. Contractor must inform the caseworker and the Mental Health and Support Services Team HS- CWServiceReferral(a.weldgov.com within three (3) days of when the client is placed on a behavioral plan or discharged 7. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Mental Health and Support Services Team HS-CWServiceReferral(Sweldgov.com immediately via email, to discuss service continuation. 8. Contractor will identify, in detail, areas of continued concern and make recommendations to the caseworker in a monthly report regarding continuation of services and/or the need for additional services. 9. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 10. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported to the caseworker and the Mental Health and Support Services Team HS- CWServiceReferralAweldgov.com immediately AND on the required monthly report. 11. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Mental Health and Support Services Team. Any changes to visitation referrals will be approved by a new referral signed by the Child Welfare Supervisor. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 12. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Mental Health and Support Services Team, and the facilitator documents in the meeting notes the timeframe that the provider attended and when participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the meeting notes. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone or virtually, if approved by the Department. 13.On a monthly basis, the Contractor will notify the Mental Health and Support Services Team HS-CWServiceReferral(afweldgov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 14. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 9 of this Exhibit. 15. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 16.1-12 Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 17. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For this purpose, Contractor will designate an e- mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be personally served. 18. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department, and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients to sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 19. Credentialing Criteria Contractor and its employee(s) and sub-contractor(s) shall remain in good standing with the Colorado Department of Regulatory Affairs (DORA) and may not, at any time during the term of this contract, be listed as excluded or debarred in the System for Award Management (SAM). Contractor shall ensure that all employees/subcontractors who provide services to clients under this contract meet the credentials/qualifications specific to the County's identified credentialing standards and C.R.S Title 12, Article 43 and in the Social Services Manual Volume 7.000.6(M) (12 CCR 2509-4). The County has the right to approve Contractor's employees/subcontractors who will be performing services under this contract prior to the commencement of the work and shall have the right to review the employee(s)'/subcontractor(s)' employment files prior to granting approval. Contractor must retain copies of employee credentialing qualifications and background checks in personnel files and make such records available to the County Representative upon request. Contractor shall obtain reference and background checks, including fingerprint -based police (CBI and/or FBI) checks (if required by statute or regulation or if them will be unsupervised contact with children), checks of County records, and Sexual Offender Registry checks and receive, at minimum, preliminary results before assigning/hiring employees/subcontractors to perform under this contract. If the County becomes dissatisfied with Contractor's employee(s)/subcontractor(s), the County will notify Contractor of its concerns about the employee(s)/subcontractor(s). Disciplinary measures, if any, will be the sole responsibility of Contractor. However, if the concerns/issues cannot resolve to the County's satisfaction, Contractor's employee(s)/subcontractor(s) may not be allowed to provide services under this contract. The County reserves the right to review all Contractor's or Sub -Contractors background checks. It is the responsibility of the Contractor to notify the County of results of background checks. EXHIBIT B RATE SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate(s) specified below in Paragraph 2, Fees for Services. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. For services funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check, deposit slip or bank letter. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. For services not funded through Core Services; Contractor agrees to accept payment through County Warrant when funding source does not allow for direct deposit. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. . 2. Fees for Services Program Area Rate Type Service Name Mental Health Services Individual/ Family Psychotherapy: Team $175.00 Hour Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing 175,00 $175.00 Hour Hour Individual/ Family Psychothen or Community Individual/ Family Psychotherapy: In- OfficeNideo individual/ Family Psychotherapy: Mileag exceeding 60 roundtr•p ea John D. Kennedy Pa way, Suite 2 Collins, Colorado 80525 Mile Program Area Rate $150.00 Type Each Service Name Individual/ Family Psychotherapy: No Show (Max of 2 no shows or 2 hours/month/client) $200.00 Hour Neuropsychological Evaluation: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $225.00 Hour Neuropsychological Evaluation: In -Home/ Community Mental Health Services'` $200.00 Hour Neuropsychological Evaluation: In -Office/ Video $0.65 Mile Neuropsychological Evaluation: Mileage exceeding 120 roundtrip miles from 3500 John D. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. $200.00 Each Neuropsychological Evaluation: No Show (Max of 2 no shows or 2 hours/month/client) 3. Request for Reimbursement and Supporting Documentation Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 45 days from the date of service for each client receiving ongoing services. Contractor shall prepare and submit monthly a Request for Reimbursement and monthly report including other supporting documentation, if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 of this Agreement. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Time(s) of service (i.e. 2-4pm) b. Location of where the service took place (i.e. clinician's office, client's home, in the community.) c. Clinician/therapist name d. What interventions were used, recommendations and/or goals discussed, progressions towards goals, and client engagement. e. For mileage reimbursement, if applicable, the mileage accumulated minus roundtrip mileage that is included in the rate, starting location, and ending location. f. Any and all safety concerns. When submitting a Request for Reimbursement for a one-time service, the contractor shall submit the first and last page of the evaluation/report to confirm proof of services rendered. The full evaluation/report should be submitted by the contractor to the caseworker. For Monitored Sobriety services, proof of services rendered shall be the test result. Requests for Reimbursement and/or supporting documentation received after the 7th day of the month may delay payment. Requests for Reimbursement and/or supporting documentation received after 45 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 45 -day deadline may result in termination of the Agreement. 4. Payment The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: The service being provided by the contractor is not a Medicaid eligible service; a. The service is not deemed medically necessary; b. The Court with jurisdiction over the case has ordered that a non - Medicaid provider or service be used; c. A Medicaid provider is not available to provide the needed service; d. Medicaid is exhausted for the needed service; or e. Medicaid denied service. f. The client is not eligible for Medicaid. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: a. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 6. Financial Management At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMB Circular A-133. ACOKD® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 08/06/2025 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 StateFarm Barry B Bailey A 838 W Drake RD Suite 109 CODe Fort Collins CO 80526 CONTACT Bar B Baffle NAME ry y 2NN , E:t): 970-493-2323 I rim. No): .'8 d@statefarm.com LODWI barry.bailey.j8qd@statefarm.com ADDRESS: Ry Y ) 4 INSURER(S) AFFORDING COVERAGE NAIL # INSURER A : State Farm Fire and Casualty Company 25143 INSURED SHARP,JEREMY T PHD LLC 1015 LINDEN GATE CT FORT COLLINS CO 805242466 INSURER B : State Farm Mutual Automobile Insurance Company 25178 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. T TYPE OF INSURANCE NSD YWD POLICY NUMBER POLICY EFF (MM/DDIY1r1^r) POLICY EXP (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Z OCCUR N N 96 -AP -F970-8 06/23/2025 06/23/2026 - EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,0N MED FRCP (Any one person) $ 5,000 PERSONAL &ADVINJURY $ 1,000,000 A GENERAL AGGREGATE $ 2,000,000 GEM_ AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECT X LOC OTHER: 0100409-000151009 $ 2,000,000 $ AUTOMOBILE B _ LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED /� AUTOS NON -OWNED AUTOS ONLY N N 509 2528 -C22 -06A 03/22/2025 09/22/2025 e laccideD SINGLE LIMIT (E $ BODILY INJURY (Per person) $ 1,000,000 BODILY INJURY (Per accident) $ 1,000,000 PROPERTY DAMAGE (Per accident) $ 1,000,000 UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED I I RETENTION $ WORKERS COMPENSATION "AZT LIABILITY N ANY PROPRIETOR/PARTNER/EXECUTIVE MI OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA I STATUTE I ERH $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ 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 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN WELD COUNTY ACCORDANCE WITH THE POLICY PROVISIONS. 315 N 11TH AVENUE BLDG A AUTHORIZED REPRESENTATIVE i P'-i.--- This form was system -generated on 08/06/2025 • GREELEY CO 80631 I ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1001486 2005 155279 205 01-19-2023 ACQREP CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/WYY) 05/02/2025 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 Trust Risk Management Services, Inc. doing business in CO as Potomac Risk Management Services, Inc. 1791 Paysphere Circle Chicago, IL 60674 CONTACT NAME: Trust Risk Management Services, Inc PHONE FAX (MAIL Ext): 877.637.9780 I (ac, No): 677.251.5111 ADDRESS: info@trustrms.com INSURER(S) AFFORDING COVERAGE NAIL Pi INSURER A: ACE American Insurance Company 22667 INSURED Dr. Jeremy T Sharp 3500 John F Kennedy Pkwy Ste 200 Fort Collins, CO 80525-2635 INSURER B: 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 SUER INSR MD POLICY NUMBER POLICY EFF (MM/DOZY , POLICY EXP (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO -T LOC JEC POLICY El❑ OTHER: GENERAL AGGREGATE $ PRODUCTS—COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS AD os NED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per Person) $ BODILY INJURY (Per accident $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A (STATUTE I IERH $ E.L.EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Psychologist's Professional Liability Retroactive Date 04/01/20O9 58622792581 04/01/2025 04/01/2026 Each Incident Annual Aggregate $1,000,000 $3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEH CLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Weld County Department of Human Services 315 N 11th Ave Bldg A 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 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Details Request Change Named Insured Insured Name: Address: Dr. Jeremy T Sharp 3500 John F Kennedy Pkwy Ste 200 Fort Collins, CO 80525-2635 Additional Parties Name Role Board of County Commissioners of Weld County and Additional Insured its Officers/Employees Colorado Center for Assessments & Counseling Business Entity Jeremy T. Sharp, PhD, LLC Business Entity Limits and Reimbursements Professional Liability: $1,000,000 / $3,000,000 Wrongful Employment Practices: $5,000 Aggregate Licensing Board Defense $5,000 per Proceeding Other Regulatory Body Defense $5,000 per Proceeding Effective Date 4/1/2020 10/19/2020 10/19/2020 SIGNATURE REQUESTED: Amendment #2 Final Audit Report 2025-09-01 Created: 2025-08-27 By: Lesley Cobb (cobboolk@weld.gov) Status: Signed Transaction ID: CBJCHBCAABAAEnsjBNLd7MOLNmUu2zn8xtYbwWDjOZdm "SIGNATURE REQUESTED: Amendment #2" History ,t Document created by Lesley Cobb (cobbxxlk@weld.gov) 2025-08-27 - 5:29:39 PM GMT- IP address: 204.133.39.9 Ley Document emaiied to dr.sharp@coloradocac.com for signature 2025-08-27 - 5:30:56 PM GMT t Email viewed by dr.sharp@coloradocac.com 2025-09-01 - 1:35:01 PM GMT- IP address: 66.102.6.228 4 Signer dr.sharp@coloradocac.com entered name at signing as Jeremy Sharp 2025-09-01 - 2:58:17 PM GMT- IP address: 73.169.17.157 4 Document e -signed by Jeremy Sharp (dr.sharp@coloradocac.com) Signature Date: 2025-09-01 - 2:58:19 PM GMT - Time Source: server- IP address: 73.169.17.157 el Agreement completed. 2025-09-01 - 2:58:19 PM GMT Powered by Adobe Acrobat Sign Contr. ct Form Entity Information Entity Name* SHARP, JEREMY Entity ID* @00017001 Q New Entity? Contract Name* Contract ID JEREMY SHARP DBA COLORADO CENTER FOR 9902 ASSESSMENT (PROFESSIONAL SERVICES AGREEMENT AMENDMENT #2 RELATED TO BID #B2300040( Contract Status CTB REVIEW Contract Lead * COBBXXLK Contract Lead Email cobbxxlk@weld.gov Parent Contract ID 20231435 Requires Board Approval YES Department Project # Contract Description" (CONSENT) JEREMY SHARP DBA COLORADO CENTER FOR ASSESSMENT (PROFESSIONAL SERVICES AGREEMENT AMENDMENT #2 RELATED TO BID #B2300040(. TERM: 8/1 /24 THROUGH 5/31/26. Contract Description 2 PA ATTACHED Contract Type* Department AGREEMENT HUMAN SERVICES Amount* $0.00 Renewable * YES Automatic Renewal Grant IGA Department Email CM- HumanServices@weld.gov Department Head Email CM-HumanServices- DeptHead@weld.gov County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WEL D.GOV If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Requested BOCC Agenda Due Date Date* 09/13/2025 09/17/2025 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? 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" 03/31/2026 Renewal Date" 06/01/2026 Committed Delivery Date Expiration Date Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date CONSENT 09/12/2025 Approval Process Department Head Finance Approver Legal Counsel JAMIE ULRICH CONSENT CONSENT DH Approved Date Finance Approved Date Legal Counsel Approved Date 09/12/2025 09/12/2025 09/12/2025 Final Approval BOCC Approved Tyler Ref # AG 092225 BOCC Signed Date Originator COBBXXLK BOCC Agenda Date 09/22/2025 Loh*vac-\ ti)t1 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND JEREMY T. SHARP, PHD, LLC DBA COLORADO CENTER FOR ASSESSMENT & COUNSELING This Agreement Amendment made and entered into t 51-1"' day of MO,AA , 2024 by and between the Board of Weld County Commissioners, on behalf of the Weld CountyVilepartment of Human Services, hereinafter referred to as the "Department", and Jeremy T. Sharp, PhD., LLC DBA Colorado Center for Assessment & Counseling, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2023-1435, approved on May 22, 2023. 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, 2024. • 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 as of June 1, 2024: 1. Paragraph 3. — Term. The term of this Agreement shall be from June 1, 2024, through May 31, 2026, unless sooner terminated as provided herein, and is subject to continued budget appropriations. • All other terms and conditions of the Original Agreement remain unchanged. 6143.4, -(kb -o) C 5iis�1da� 6/is/a� H�5� IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: jeita;g1 BY: lerk to the Bo J.✓�ati�i�►A� Deputy C; rk to e BOARD OF COUNTY COMMISSIONERS WELD COUN'et-rCOLORADO- evin D. Ross, Chair NTRACTOR: MAY 1 5 2024 Jeremy T. Sharp Ph.D., LLC DBA Colorado Center for Assessment & Counseling 3500 John F. Kennedy Parkway, Suite 200 Fort Collins, Colorado 80525 (970) 541-9932 Jereo1 Sharp By: Jeremy Sharp ( ay 1, 2024 11.14 M D, Jeremy Sharp, Ph.D., Director and Licensed Psychologist Date: May 1, 2024 2023-11-\35 SIGNATURE REQUESTED: Weld/Colorado Center for Assessment & Counseling Amendment #1 Final Audit Report 2024-05-01 Created 2024-05-01 By: Windy Luna (wluna c@weld.gov) Status: Signed Transaction ID: CBJCHBCAABAAm-oriaFhBYsHamSY7G-bNGIZDDOZc3EJ "SIGNATURE REQUESTED: Weld/Colorado Center for Assess ment & Counseling Amendment #1" History 5 Document created by Windy Luna (wluna@weld.gov) 2024-05-01 - 3:59:00 PM GMT- IP address: 204.133.39.9 2, Document emailed to dr.sharp@coloradocac.com for signature 2024-05-01 - 3:59:32 PM GMT e Email viewed by dr.sharp@coloradocac.com 2024-05-01 - 5:14:09 PM GMT- IP address: 74.125.215.71 £I5j Signer dr.sharp@coloradocac.com entered name at signing as Jeremy Sharp 2024-05-01 - 5:14:47 PM GMT- IP address: 71.205.30.99 4 Document e -signed by Jeremy Sharp (dr.sharp@coloradocac.com) Signature Date: 2024-05-01 - 5:14:49 PM GMT - Time Source: server- IP address: 71.205.30.99 Agreement completed. 2024-05-01 - 5:14:49 PM GMT Powered by Adobe Acrobat Sign Contract Form Entity Information Entity Name * SHARP, JEREMY Entity ID* @00017001 Contract Name* JEREMY SHARP DBA COLORADO CENTER FOR ASSESSMENT (PROFESSIONAL SERVICES AGREEMENT AMENDMENT #1 RELATED TO BID #BB2300040) Contract Status CTB REVIEW Contract ID 8135 Contract Lead WLUNA O New Entity? Parent Contract ID 20231435 Requires Board Approval YES Contract Lead Email Department Project # wluna@weldgov.com;cob bxxlk@weldgov.com Contract Description* (CONSENT) JEREMY SHARP DBA COLORADO CENTER FOR ASSESSMENT (PROFESSIONAL SERVICES AGREEMENT AMENDMENT #1 RELATED TO BID #BB2300040). TERM: 6/1 /24 THROUGH 5/31 /26. Contract Description 2 PROVIDER WAS LISTED ON APPROVED VENDOR LIST PRESENTED TO THE BOCC ON 04/10/24. Contract Type" AGREEMENT Amount* $ 0.00 Renewable* YES Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServices@weldgov. com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WEL DGOV.COM Requested BOCC Agenda Due Date Date* 05/09/2024 05/13/2024 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Termination Notice Period Contact Information Review Date * 03/31/2025 Renewal Date* 06/01/2025 Committed Delivery Date Expiration Date Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date CONSENT 05/09/2024 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-ya c+ I k (0(39 7 PROFESSIONAL SERVICE AGREEMENT BETWEEN WELD COUNTY AND JEREMY T. SHARP, PHD. LLC DBA COLORADO CENTER FOR ASSESSMENT & COUNSELING THIS AGREEMENT is made and entered into this Wn d'ay of 2023, by and between the Board of Weld County Commissioners, on behalf of the Weld County De ent of Human Services, hereinafter referred to as "County," and Jeremy T. Sharp, PhD., LLC DBA Colorado Center for Assessment & Counseling, hereinafter referred to as "Contractor". WHEREAS, County desires to retain Contractor to perform services as required by County and set forth in the attached Exhibits; and WHEREAS, Contractor is willing and has the specific ability, qualifications, and time to perform the required services according to the terms of this Agreement; and WHEREAS, Contractor is authorized to do business in the State of Colorado and has the time, skill, expertise, and experience necessary to provide the services as set forth below; and WHEREAS, the Colorado Department of Human Services has provided Core and Non -Core or other funding to the Department for Mental Health Services. NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties hereto agree as follows: L Introduction. The terms of this Agreement are contained in the terms recited in this document and in the attached Exhibits, each of which forms an integral part of this Agreement and are incorporated herein. The parties each acknowledge and agree that this Agreement, including the attached Exhibits, define the performance obligations of Contractor and Contractor's willingness and ability to meet those requirements (the "Work"). If a conflict occurs between this Agreement and any Exhibit or other attached document, the terms of this Agreement shall control, and the remaining order of precedence shall based upon order of attachment. Exhibit A consists of the Scope of Services. Exhibit B consist of the Rate Schedule, Exhibit C consists of County's Request for Proposal (RFP) as set forth in Bid Package No. 132300040 which is incorporated into this agreement by reference and will be provided upon request to the Department. Exhibit D consists of Contractor's Response to County's Request. 2. Service or Work. Contractor agrees to diligently provide all services, labor, personnel and materials necessary to perform and complete the Work described in the attached Exhibits. Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibits A, Scope of Services, and Exhibit D, Contractor's Response to Request for Proposal. Contractor shall further be responsible for the timely completion and acknowledges that a failure to comply with the standards and requirements of Work within the time limits prescribed by County may result in County's decision to withhold payment or to terminate this Agreement. Con5tn-1- 11-cfnob, 5/22/23 at -444,0-p-) *2-21-2-L5 2023-1435 14.12-Ul'15 3. Tam. The term of this Agreement shall be from June 1. 2023, through May 31, 2024, unless sooner terminated as provided herein. Both of the parties to this Agreement understand and agree that the laws of the State of Colorado prohibit County from entering into Agreements which bind County for periods longer than one year. This Agreement may be renewed for 2 (two) additional one-year terms upon mutual written agreement of the Parties. 4. Termination; Breach; Cure. County may terminate this Agreement for its own convenience upon thirty (30) days written notice to Contractor. Either Party may immediately terminate this Agreement upon material breach of the other party, however the breaching party shall have fifteen (15) days after receiving such notice to cure such breach. If this Agreement is terminated by County, Contractor shall be compensated for, and such compensation shall be limited to, (1) the sum of the amounts contained in invoices which it has submitted and which have been approved by the County; (2) the reasonable value to County of the services which Contractor provided prior to the date of the termination notice, but which had not yet been approved for payment; and (3) the cost of any work which the County approves in writing which it determines is needed to accomplish an orderly termination of the work. County shall be entitled to the use of all material generated pursuant to this Agreement upon termination. Upon termination of this Agreement by County, Contractor shall have no claim of any kind whatsoever against the County by reason of such termination or by reason of any act incidental thereto, except for compensation for work satisfactorily performed and/or materials described herein properly delivered. 5. Extension or Amendment. Any amendments or modifications to this agreement shall be in writing signed by both parties. No additional services or work performed by Contractor shall be the basis for additional compensation unless and until Contractor has obtained written authorization and acknowledgement by County for such additional services. Accordingly, no claim that the County has been unjustly enriched by any additional services, whether or not there is in fact any such unjust enrichment, shall be the basis of any increase in the compensation payable hereunder. In the event that written authorization and acknowledgment by the County for such additional services is not timely executed and issued in strict accordance with this Agreement, Contractor's rights with respect to such additional services shall be deemed waived and such failure shall result in non-payment for such additional services or work performed. Any claims by the Contractor for adjustment hereunder must be made in writing prior to performance of any work covered in the anticipated Amendment, unless approved and documented otherwise by the County Representative. Any change in work made without such prior Amendment shall be deemed covered in the compensation and time provisions of this Agreement, unless approved and documented otherwise by the County Representative. 6. Compensation. County agrees to pay Contractor through an invoice process during the course of this Agreement in accordance with the Rate Schedule as described as Exhibit B. Contractor agrees to submit invoices which detail the work completed by Contractor. The County will review each invoice and if it agrees Contractor has completed the invoiced items to the County's satisfaction, it will remit payment to the Contractor. No payment in excess of that set forth in the Exhibits will be made by County unless an Amendment authorizing such additional payment has been specifically approved by Weld County as required pursuant to the Weld County Code. If, at any time during the term or after termination or expiration of this Agreement, County reasonably determines that any payment made by County to Contractor was improper because the service for which payment was made did not perform as set forth in this Agreement, then upon written notice of such determination and request for reimbursement from County, Contractor shall forthwith return such payment(s) to County. Upon termination or expiration of this Agreement, unexpended funds advanced by County, if any, shall forthwith be returned to County. County wil not withhold any taxes from monies paid to the Contractor hereunder and Contractor agrees to be solely responsible for the accurate reporting and payment of any taxes related to payments made pursuant to the terms of this Agreement. Unless expressly enumerated in the attached Exhibits, Contractor shall not be entitled to be paid for any other expenses (e.g. mileage). Notwithstanding 2 anything to the contrary contained in this Agreement, County shall have no obligations under this Agreement after, nor shall any payments be made to Contractor in respect of any period after December 31 of any year, without an appropriation therefore by County in accordance with a budget adopted by the Board of County Commissioners in compliance with Article 25, Title 30 of the Colorado Revised Statutes, the Local Government Budget Law (C.R.S. 29-1-101 et. seq.) and the TABOR Amendment (Colorado Constitution, Article X, Sec. 20). 7. Independent Contractor. Contractor agrees that it is an independent contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits (including unemployment insurance or workers' compensation benefits) from County as a result of the execution of this Agreement. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. 8. Subcontractors. Contractor acknowledges that County has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of the Work without County's prior written consent, which may be withheld in County's sole discretion. County shall have the right in its reasonable discretion to approve all personnel assigned to the Work during the performance of this Agreement and no personnel to whom County has an objection, in its reasonable discretion, shall be assigned to the Work. Contractor shall require each subcontractor, as approved by County and to the extent of the Work to be performed by the subcontractor, to be bound to Contractor by the terms of this Agreement, and to assume toward Contractor all the obligations and responsibilities which Contractor, by this Agreement, assumes toward County. County shall have the right (but not the obligation) to enforce the provisions of this Agreement against any subcontractor hired by Contractor and Contractor shall cooperate in such process. The Contractor shall be responsible for the acts and omissions of its agents, employees and subcontractors. 9. Ownership. All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of County. In addition, all reports, documents, data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the County. Contractor shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of County. 10. Confidentiality. Confidential information of the Contractor should be transmitted separately from non -confidential information, clearly denoting in red on the relevant document at the top the word, "CONFIDENTIAL." However, Contractor is advised that as a public entity, Weld County must comply with the provisions of the Colorado Open Records Act (CORA), C.R.S. 24-72-201, et seq., with regard to public records, and cannot guarantee the confidentiality of all documents. Contractor agrees to keep confidential all of County's confidential information. Contractor agrees not to sell, assign, distribute, or disclose any such confidential information to any other person or entity without seeking written permission from the County. Contractor agrees to advise its employees, agents, and consultants, of the confidential and proprietary nature of this confidential information and of the restrictions imposed by this Agreement. 3 11. Warranty. Contractor warrants that the Work performed under this Agreement will be performed in a manner consistent with the standards governing such services and the provisions of this Agreement. Contractor further represents and warrants that all Work shall be performed by qualified personnel in a professional manner, consistent with industry standards, and that all services will conform to applicable specifications. 12. Acceptance of Services Not a Waiver. Upon completion of the Work, Contractor shall submit to County originals of all test results, reports, etc., generated during completion of this work. Acceptance by County of reports and incidental material(s) furnished under this Agreement shall not in any way relieve Contractor of responsibility for the quality and accuracy of the project. In no event shall any action by County hereunder constitute or be construed to be a waiver by County of any breach of this Agreement or default which may then exist on the part of Contractor, and County's action or inaction when any such breach or default exists shall not impair or prejudice any right or remedy available to County with respect to such breach or default. No assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the County of, or payment for, the Work completed under this Agreement shall not be construed as a waiver of any of the County's rights under this Agreement or under the law generally. 13. Insurance. Contractor must secure, before the commencement of the Work, the following insurance covering all operations, goods, and services provided pursuant to this Agreement, and shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, and during any warranty period. For all coverages, Contractor's insurer shall waive subrogation rights against County. Types of Insurance. Workers' Compensation /Employer's Liability Insurance as required by state statute, covering all of the Contractor's employees acting within the course and scope of their employment. The policy shall contain a waiver of subrogation against the County. This requirement shall not apply when a Contractor or subcontractor is exempt under Colorado Workers' Compensation Act., AND when such Contractor or subcontractor executes the appropriate sole proprietor waiver form. Commercial General Liability Insurance including public liability and property damage, covering all operations required by the Work. Such policy shall include minimum limits as follows: $1,000,000 each occurrence; $1,000,000 general aggregate; $1,000,000 Personal injury; $5,000 Medical payment per person. Automobile Liability Insurance: Contractor shall maintain limits of $1,000,000 for bodily injury per person, $1,000,000 for bodily injury for each accident, and $1,000,000 for property damage applicable to all vehicles operating both on County property and elsewhere, for vehicles owned, hired, and non -owned vehicles used in the performance of this Contract. Professional Liability (Errors and Omissions Liability). The policy shall cover professional misconduct or lack of ordinary skill for those positions defined in the Scope of Services of this contract. Contractor shall maintain limits for all claims covering wrongful acts, errors and/or omissions, including design errors, if applicable, for damage sustained by reason of or in the course of operations under this Contract resulting from professional services. En the event that the professional liability insurance required by this Contract is written on a claims -made basis, Contractor warrants that any retroactive date under the policy shall precede the effective date of this Contract; and that either continuous coverage will be maintained or an extended discovery 4 period will be exercised fora period of two (2) years beginning at the time work under this Contract is completed. Minimum Limits: $1,000,000 Per Loss; $2,000,000 Aggregate. b. Proof of Insurance. Upon County's request, Contractor shall provide to County a certificate of insurance, a policy, or other proof of insurance as determined in County's sole discretion. County may require Contractor to provide a certificate of insurance naming Weld County, Colorado, its elected officials, and its employees as an additional named insured. c. Subcontractor Insurance. Contractor hereby warrants that all subcontractors providing services under this Agreement have or will have the above described insurance prior to their commencement of the Work, or otherwise that they are covered by the Contractor's policies to the minimum limits as required herein. Contractor agrees to provide proof of insurance for all such subcontractors upon request by the County. d. No limitation of Liability. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. The County in no way warrants that the minimum limits contained herein are sufficient to protect the Contractor from liabilities that might arise out of the performance of the Work under by the Contractor, its agents, representatives, employees, or subcontractors. The Contractor shall assess its own risks and if it deems appropriate and/or prudent, maintain higher limits and/or broader coverages. The Contractor is not relieved of any liability or other obligations assumed or pursuant to the Contract by reason of its failure to obtain or maintain insurance in sufficient amounts, duration, or types. The Contractor shall maintain, at its own expense, any additional kinds or amounts of insurance that it may deem necessary to cover its obligations and liabilities under this Agreement. e. Certification of Compliance with Insurance Requirements. The Contractor stipulates that it has met the insurance requirements identified herein. The Contractor shall be responsible for the professional quality, technical accuracy, and quantity of all services provided, the timely delivery of said services, and the coordination of all services rendered by the Contractor and shall, without additional compensation, promptly remedy and correct any errors, omissions, or other deficiencies. 14. Indemnity. The Contractor shall defend, indemnify and hold harmless County, its officers, agents, and employees, from and against any and all injury, loss, damage, liability, suits, actions, claims, or willful acts or omissions of any type or character arising out of the Work done in fulfillment of the terms of this Agreement or on account of any act, claim or amount arising or recovered under workers' compensation law or arising out of the failure of the Contractor to conform to any statutes, ordinances, regulation, judicial decision, or other law or court decree. The Contractor shall be fully responsible and liable for any and all injuries or damage received or sustained by any person, persons, or property on account of its performance under this Agreement or its failure to comply with the provisions of the Agreement. It is agreed that the Contractor will be responsible for primary loss investigation, defense and judgment costs where this contract of indemnity applies. In consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the County its associated and/or affiliated entities, successors, or assigns, its elected officials, trustees, employees, agents, and volunteers for losses arising from the work performed by the Contractor for the County. A failure to comply with this provision shall result in County's right to immediately terminate this Agreement. 15. Non -Assignment. Contractor may not assign or transfer this Agreement or any interest therein or claim thereunder, without the prior written approval of County. Any attempts by Contractor to assign or transfer its rights hereunder without such prior approval by County shall, at the option of County, automatically terminate this Agreement and all rights of Contractor hereunder. Such consent may be granted or denied at the sole and absolute discretion of County. 16. Examination of Records. To the extent required by law, the Contractor agrees that an duly authorized representative of County, including the County Auditor, shall have access to and the right to►examine and audit any books, documents, papers and records of Contractor, involving all matters and/or transactions related to this Agreement. Contractor agrees to maintain these documents for three years front the date of the last payment received. 17. Interruptions. Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. 18. Notices. County may designate, prior to commencement of Work, its project representative ("County Representative") who shall make, within the scope of his or her authority, all necessary and proper decisions with reference to the project. All requests for contract interpretations, change orders, and other clarification or instruction shall be directed to County Representative. All notices or other communications made by one party to the other concerning the terms and conditions of this contract shall be deemed delivered under the following circumstances: (a) personal service by a reputable courier service requiring signature for receipt; or (1,1 five (5) days following delivery to the United States Postal Service, postage prepaid addressed to a party at the address set forth in this contract; or (c) electronic transmission via email at the address set forth below, where a receipt or acknowledgment is required and received by the sending party; or Either party may change its notice address(es) by written notice to the other. Notice may be sent to: TO CONTRACTOR: Name: Jeremy T. Sharp. PhD. Position: Director and Licensed Psychologist Address: 3500 John F. Kennedy Parkway. Suite 200 Address: Fort Collins. Colorado 80525 E-mail: contact@coloradocac.com Phone: (970) 541-9932 TO COUNTY: Name: Jamie Ulrich Position: Director Address: P.O. Box A Address: Greeley. Colorado 80632 E-mail: julrich@weld.gov Phone: (970) 400-6510 19. Compliance with Law. Contractor shall strictly comply with all applicable federal and State laws, rules and regulations in effect or hereafter established, including without limitation, laws applicable to discrimination and unfair employment practices. 20. Non -Exclusive Agreement. This Agreement is nonexclusive and County may engage or use other Contractors or persons to perform services of the same or similar nature. 6 21. Entire Agreement/Modifications. This Agreement including the Exhibits attached hereto and incorporated herein, contains the entire agreement between the parties with respect to the subject matter contained in this Agreement. This instrument supersedes all prior negotiations, representations, and understandings or agreements with respect to the subject matter contained in this Agreement. This Agreement may be changed or supplemented only by a written instrument signed by both parties. 22. Fund Availability. Financial obligations of the County payable after the current fiscal year are contingent upon funds for that purpose being appropriated, budgeted and otherwise made available. Execution of this Agreement by County does not create an obligation on the part of County to expend funds not otherwise appropriated in each succeeding year. 23. Employee Financial Interest/Conflict of Interest — C.R.S. §§24-18-201 et seq. and §24-50-507. The signatories to this Agreement state that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. 24. Survival of Termination. The obligations of the parties under this Agreement that by their nature would continue beyond expiration or termination of this Agreement (including, without limitation, the warranties, indemnification obligations, confidentiality and record keeping requirements) shall survive any such expiration or termination. 25. Severability. If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. 26. Governmental Immunity. No term or condition of this Agreement shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act §§24-10-101 et seq., as applicable now or hereafter amended. 27. No Third Party Beneficiary. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 28. Board of County Commissioners of Weld County Approval. This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado or its designee. 29. Choice of Law/Jurisdiction. Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 30. Attorney's Fees/Legal Costs. In the event of a dispute between County and Contractor concerning this Agreement, the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf. 7 31. Binding Arbitration Prohibited. Weld County does not agree to binding arbitration by any extra- judicial body or person. Any provision to the contrary in this Agreement or incorporated herein by reference shall be null and void. 32. Acknowledgment. County and Contractor acknowledge that each has read this Agreement, understands it and agrees to be bound by its terms. Both parties further agree that this Agreement, with the attached Exhibits, is the complete and exclusive statement of agreement between the parties and supersedes all proposals or prior agreements, oral or written, and any other communications between the parties relating to the subject matter of this Agreement. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: ~' 4) W ;‘i BY: to the Board Deputy Clergy to the Boar'1 r 1 361 al 8 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ike Freeman, Chair MAY 2 2 2323 ONTRACTOR: Jeremy T. Sharp Ph.D., LLC DBA Colorado Center for Assessment & Counseling 3500 John F. Kennedy Parkway, Suite 200 Fort Collins, Colorado 80525 (970) 541-9932 jeteivl Shoup By: Jeremy Sharp May 11,'107.16:17 MDT) Jeremy Sharp, Ph.D., Director and Licensed Psychologist Date: "11'2'3 EXHIBIT A SCOPE OF SERVICES Contractor will provide Mental Health Services, as referred by the Department. 1. Group Psychotherapy Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Dialectical behavior therapy. ii. Parenting support. iii. Interpersonal process. iv. Psychoeducation. b. Anticipated Frequency of Services: i. Sixty (60) to ninety (90) minutes in duration, per session. ii. Contractor can provide groups weekly, biweekly, and monthly depending on the type of the group. c. Anticipated Duration of Services: i. Six (6) to eight (8) weeks. d. Goals of Services: i. Healthier coping skills. ii. Better social skills. iii. Decreased isolation. e. Outcomes of Services: i. Healthier coping skills. ii. Better social skills. iii. Decreased isolation. f. Target Population: i. Children ages five (5) to seventeen (17). ii. Adults of all ages. iii. Any gender. iv. Any cultural backgrounds. g. Language: i. English h. Medicaid Eligibility: i. This service is Medicaid eligible. Service Access and Transportation: i. In office located at 3500 John F. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. ii. Telehealth. 2. Individual/Family Psychotherapy a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Psychotherapy will utilize modalities that include, but are not limited to: 1. Cognitive Behavioral Therapy (CBT). 2. Dialectical Behavior Therapy (DBT). 3. Mindfulness -based services. 4. Interpersonal therapy. 5. Exposure with response prevention. 6. Eye Movement Desensitization and Reprocessing (EMDR). b. Anticipated Frequency of Services: i. Initial session, sixty (60) minutes in duration. ii. Following sessions, thirty (30) to sixty (60) minutes, depending on client severity and needs. o, Anticipated Duration of Services: i. Varies depending on goal of the group and intensity of the presenting problem. ii. Sessions can occur multiple times weekly, bi-weekly, or monthly, depending on the client's severity and needs. d. Goals of Services: i. Provide quality. ethical services, as requested by the Department, in order to support Department staff and clients with mental health needs. e. Outcomes of Services: i. Improved mental health in various capacities. f. Target Population: i. Children ages five (5) to seventeen (17). ii. Adults of all ages. iii. Any gender. iv. Clients with a variety of presenting concems and diagnoses. g. Language: i. English h. Medicaid Eligibility: i. This service is Medicaid eligible. Service Access and Transportation: i. In office located at 3500 John F. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. ii. Telehealth. 3. Neuropsychological Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Assessment will utilize standard measures including, but not limited, to the following tests: 1. Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV). 2. Wechsler Intelligence Scale for Children® Fifth Edition (WISC-V). 3. Wechsler Individual Achievement Test, Third Edition (WIAT-IlI). 4. Kaufman Test of Educational Achievement 3rd Edition (KTEA-3). 5. Comprehensive Test of Phonological Processing 2 (CTOPP-2). 6. California Verbal Learning Test® Children's Version (CVLT-C). 7. CVLT-3. 8. Rey—Osterrieth Complex Figure (RCFT). 9. Conners Continuous Performance Test 3rd Edition (CCPT3). 10. Conners Kiddie Continuous Performance Test 2nd Edition (KCPT-2). 11. Autism Diagnostic Observation Schedule -Second Edition (ADOS-2). 12. Behavior Assessment System for Children, Third Edition (BASC-3). 13. Behavior Rating Inventory of Executive Function, Second Edition (BRIEF -2). 14. Social Responsiveness Scale, Second Edition (SRS -2). 15. Adaptive Behavior Assessment System Third Edition (ABAS-3). b. Anticipated Frequency of Services: i. Initial interview, two (2) hours. ii. Testing, four (4) to six (6) hours. iii. Final feedback session, one (1) hour, c. Anticipated Duration of Services: i. Three (3) to four (4), appointments. ii. Three (3) to six (6), weeks, duration. d. Goals of Services: i. Provide comprehensive, strengths -based recommendations. ii. Facilitate growth, progress, and meet the requested outcomes. e. Outcomes of Services: i. Match both client and Department's needs. ii. Diagnostic clarity. iii. Appropriate treatment recommendations. iv. Facilitation of referral connections. E Target Population: i. Children ages two and a half (2 ''/z) to seventeen (17). ii. Adults eighteen (18) and older. iii. Any gender. iv. Any sexual orientation. g. Language: i. English. ii. Spanish interpreter services available, h. Medicaid Eligibility: i. This service is Medicaid eligible. i. Service Access and Transportation: i. In office located at 3500 John F. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. ii. Telehealth. Terms 1. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. 2. Contractor agrees to receive referrals for services through e-mail and will provide an identified e-mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. 3. Contractor will respond to the Mental Health and Support Services Team CWServiceReferraltRweldeov.com) within three (3) business days regarding the ability to accept the received referral. 4. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Mental Health and Support Services Team HS- CWServiceReferraMweldeov.com. 5. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Mental Health and Support Services Team HS-CWServiceReferraltla weldgov.cam. No other Department staff or other party to the case may authorize services or modifications to services. 6. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit B, Rate Schedule, then Contractor understands that the Department will not reimburse for "no-shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharge the client from services. Contractor must inform the caseworker and the Mental Health and Support Services Team HS- CWServleeReferrallatweideov.com within three (3) days of when the client is placed on a behavioral plan or discharged 7. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Mental Health and Support Services Team HS-CWServtceReferrallbtwetdeov.com immediately via email, to discuss service continuation. 8. Contractor will identify, in detail, areas of continued concern and make recommendations to the caseworker in a monthly report regarding continuation of services and/or the need for additional services. 9. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 10. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported to the caseworker and the Mental Health and Support Services Team HS-CWServiceReferratlthweldeov.com immediately AND on the required monthly report. 11. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Mental Health and Support Services Team. Any changes to visitation referrals will be approved by a new referral signed by the Child Welfare Supervisor. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 12. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Mental Health and Support Services Team, and the facilitator documents in the meeting notes the timeframe that the provider attended and when participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the meeting notes. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone or virtually, if approved by the Department. 13. On a monthly basis, the Contractor will notify the Mental Health and Support Services Team HS- CWServiceReferralCdawetdgov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 14. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 9 of this Exhibit. 15. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 16. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 17. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will retum a waiver of services within 72 business hours. For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be personally served. 18. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department, and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients to sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. EXHIBIT B RATE SCHEDULE 1 unding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate(s) specified below in Paragraph 2, Fees for Services. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. For services funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check, deposit slip or bank letter. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. For services not funded through Core Services; Contractor agrees to accept payment through County Warrant when funding source does not allow for direct deposit. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Unit I'ragratm Area Rate Sorvice Name Tvpc Mental Health Services 160.00 50.00 50.00 160.00 175.00 $ 160.00 Group Psychology: Team Meeting Hour (FTM), Team. Decision Making (TDM) Meetinng, Professional Staffs. Each Group Psychology: In-OfficeNideo Each Group Psychology: No Show (Max of 2 no shows or 2 hours/month/client) Individual/ Family Psychotherapy: Team Hour Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing Hour Individual/ Family Psychotherapy: In - Home or Community Hour Individual/ Family Psychotherapy: In- Office/Video 0.65 Mile Individual/ Family Psychotherapy: Mileage exceeding 60 roundtrip miles from 3500 John D. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. Individual/ Family Psychotherapy: No $ 120.00 Each Show (Max of 2 no shows or 2 hours/month/client) Neuropsychological Evaluation: Team $ 175.00 Hour Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $ 225.00 i Hour Neuropsychological Evaluation: In- Home/ Community 1'ro„ram :itch Mental Health Services hale $ 175.00 Unit '.vpe Hour Service Name Neuropsychological Evaluation: In - Office/ Video $ 0.65 Mile Neuropsychological Evaluation: Mileage exceeding 120 roundtrip miles from 3500 John D. Kennedy Parkway, Suite 200, Fort Collins, Colorado 80525. $ 175.00 Each Neuropsychological Evaluation: No Show (Max of 2 no shows or 2 hours/month/client) 3. Request for Reimbursement and Supporting Documentation Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 45 days from the date of service for each client receiving ongoing services. Contractor shall prepare and submit monthly a Request for Reimbursement and monthly report including other supporting documentation, if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 of this Agreement. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Time(s) of service (i.e. 2-4pm) b. Location of where the service took place (i.e. clinician's office, client's home, in the community.) c. Clinician/therapist name d. What interventions were used, recommendations and/or goals discussed, progressions towards goals, and client engagement. e. For mileage reimbursement, if applicable, the mileage accumulated minus roundtrip mileage that is included in the rate, starting location, and ending location. f Any and all safety concerns. When submitting a Request for Reimbursement for a one -tune service, the contractor shall submit the first and last page of the evaluation/report to confirm proof of services rendered. The full evaluation/report should be submitted by the contractor to the caseworker. For Monitored Sobriety services, proof of services rendered shall be the test result. Requests for Reimbursement and/or supporting documentation received after the 7. day of the month may delay payment. Requests for Reimbursement and/or supporting documentation received after 45 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 45 -day deadline may result in termination of the Agreement. 4. Payment The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: The service being provided by the contractor is not a Medicaid eligible service; a. The service is not deemed medically necessary; b. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; c. A Medicaid provider is not available to provide the needed service; d. Medicaid is exhausted for the needed service; or e. Medicaid denied service. The client is not eligible for Medicaid. The Department may withhold reimbursement if Contractor has failed to comply with my part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: a. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 6. Financial Management At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMB Circular A-133. Exhibit C WELD COUNTY'S REQUEST FOR PROPOSAL (Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon request to the Department.) This page is intentionally left blank Exhibit D Contractor's response to the Request for Proposal Exhibit D contains the following documents: • Attachment B — Provider Information Form (PIF) • Attachment C — Proposal • Attachment D — Staff Data Sheet • Certificate of Insurance (COI) ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES — PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION Agency Name: Colorado Center for Assessment and Counseling Trails Provider ID (if known): Provider Contact Full Name: Jeremy Sharp, PhD Title: Director and Licensed Psycholog Primary Phone Number (lo -digit): (970) 541-9932 contact@coloradocac.com Primary Contact Email: Ext.: 8884943756 Fax Number (lo -digit): Web Address: www.coloradocac.com 3500 John F Kennedy Parkway, Suite 200, Fort Collins, CO 80525 Agency Location Address (Street, city, state, zip): 3500 John F. Kennedy Pkwy, Suite 200, Fort Collins, CO 80525 Agency Mailing Address (street, city, state, zip): Agency Type (pick one): El Public Company ® Private Non -Profit El Private for Profit Send Referrals for Service to: Referral Contact Name: Hayley Lewis Title: Partnerships Coordinator 9708898204 Referral Phone Number (10 -digit): Ext. info@coloradocac.com Email: Billing Contact Latecia Frisina Billing Contact Name: 9708898204 Billing Phone Number (io-digit): Ext.: 3 Title: Billing Specialist admin@coloradocac.com Email: 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 O8-03551-0000. rl Authorized Rep. Full Name: �Iharp Title: talle#ttOr Authorized Rep. Email: cirlitwri@belegictorearccom Phone (lo -digit): "44)4932 Ext.: ( sash sh.4 6.4 zsneeby. Bkwpp5sai&e2200, Fort Collins, CO 80525 RAuthorized Rep. Address (street, city, state, zip): �✓ € Y2023 t Signature of Authorized Rep.: stay 1!2421 tG'ttMDT) Date. REV. DECEMBER 2021 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. Bidder's Legal Name: Program Area: SECTION 1— Provider and Program Area Information Jeremy T Sharp, PhD, LLC dba Colorado Center for Assessment and Counseling Mental Health Services Program Areas are listed in column 1 of the table located in Item XI of the Request for Proposal starting on page 13. Number of services offered on this Attachment C (max 5): You may complete another Attachment C if you have more than S. 3 r 4 SECTION 2 - Service Name(s) and Information If the service is a monthly package, please offer different levels. All monthly packages must state a specific minimum number of direct service hours. Service #1 Name: Neuropsychological Evaluation 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Assessment will utilize standardized measures including but not limited to the following tests WAIS-IV WISC-V WIAT-Ill. KTEA-3 CTOPP-2, CVLT-C CVLT-3 RCFT CCPT3 KCPT-2 ADOS-2 BASC-3. BRIEF -2 SRS -2 ABAS-3 2.1b Anticipated frequency of direct service time with the client/tamely per week, not including professional stalling time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: The initial interview is 2 hours. testing can be anywhere between 4-6 hours. and a final feedback session usually takes 1 hour. 2.1c Anticipated duration of service (i.e. 3-4 months): Neuropsychological evaluation at our agency consists of 3-4 appointments taking place over 4-6 weeks. 2.1d Three (3). or more, specific goals of the service (DO use bullet points): To provide comprehensive, strengths -based recommendations following the assessment of Weld County clients in orde 2.1e facilitate growth, progress, and meet the requested outcomes as best we can. We hope to tailor outcomes to each individual client and match the outcome to both client needs and Weld County staff needs Common outcomes include diagnostic 'clarity, appropriate treatment recommendations and facilitation of referral connections 2.1f i arget population or the service, incivaing age ana gender: Our target population for evaluation includes children ages 2.5-17 and adults 18 and older of any gender or sexual orientation 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English, Spanish interpreter services available 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: rleuropsychological evaluation is fully covered by Medicaid clients with Rocky Mountain Health Plans - Medicaid and can be fully covered for clients with other RAE assignments if we are testing for ASD SLD or ID 2.11 Service location — list wnere me service will take place (i.e. ciient-s norne, in -orrice, caner) II n -Office, some appointments offered via telehealth Service #2 Name: Individual Psychotherapy 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Psychotherapy will utilize modalities that include but ate not limited to CBT DBT mindfulness -based services interpersonal therapy exposure with response prevention and EM DR 2.2b Anticipated trequency of direct service time with the client/tamily per week, not including protessional staffing time, administrative time, overhead, or travel time a (i.e. 4 hours/week). If the service has levels, be specific for each level: Initial sessions are 60 minutes. and following sessions can be anywhere from 30-60 depending on client severity and needs. 2.2c Anticipated duration of service (i.e. 3-4 months): [Psychotherapy can last anywhere from several weeks or months to many years and sessions can occur multiple times a week weekly biweekly or monthly depending on client several: and needs 2.2d i wee ph, or more, speciric goals or the service tut) use pullet points); To provide quality ethical services as requested by Weld County staff in order to support We d County staff and clients with mental health needs 2.2e Three (3), or more, specific outcomes of service: Common psychotherapy outcomes include improved mental health in various capacities 1 2.2f Target population of the service: Our 'arlet population fo+ psychotherapy would he children ages 5-17 and adults of all ages and genders with a variety of presenting concerns and diagnoses 2.2g Languages service is available in (please list proficiency and if interpreter services are available): English only at this time 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Clients with Rocky Mountain Health Plans or CO Access Medicaid should be covered for psychotherapy services 2.2i Service location — list where the service will take place (i.e. client's home, in -office, other) fin -Office, some appointments offered via teieheaith REV. OCT 2021 1 ATTACHMENT C - PROPOSAL Service #3 Name: Group Psychotherapy 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Dialectical behavior therapy, parenting support, interpersonal process, psychoeducation 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: IGroup sessions are at least 60 minutes long and can occur weekly, biweekly, or monthly depending on the type of group 2.3c Anticipated duration of service (i.e. 3-4 months): Groups may last 6-8 weeks or can continue past the 8 week mark with a set of clients, lasting for another 6-8 weeks, and so on 2.3d Three (3), or more, specific goals of the service (DO use bullet points): Depending on the group: 1. Healthier coping skills 2. Better social skills 3. Decreased isolation 2.3e Three (3), or more, specific outcomes of service: [Dependingon the group: 1. Healthier coping skills 2. Better social skills 3. Decreased isolation 2.3f Target population of the service: Children age 5-17 and adults of all ages. genders, and ethnic cultural backgrounds J 2.3g Languages service is available in (please list proficiency and if interpreter services are available): {English, only for the time being - 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Clients with Rocky Mountain Health Plans or Colorado Access can expect to receive coverage for group psychotherapy 2.31 Service location — list where the service will take place (i.e. client's home, in -office, other) Group sessions can occur in office or via telehealth. Service #4 Name: L 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) i 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: REV. OCT 2021 2 ATTACHMENT C - PROPOSAL 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part 2.6i Service location — list where the service will take place (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. 17 fl YES YES NO 120 ■ ■ Miles NO NO 3.5 When you calcu ate mileage, what is your starting point address? 3500 John F Kennedy Pkwy, Suite 200, Fart Collins, CO $05 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: Neuropsychological Evaluation $ Amount 4.1a In-Office/Video: 4.1b In -Home or Community: 4.1c In-Office/Video, In -Home, or Community with Transportation: 4.1d FTM, TDM, Prof. Staffing: 4.1e No show: 4.1f Mileage rate: Unit Type Select Unit Type. Select Unit Type. Select Unit Type. per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included in rate: 120 120 This is paid after the miles listed above. miles miles 4.2 Hourly Service #2 Name: Individual Psychotherapy 4.2a In-Office/Video: 4.2b In -Home or Community: 4.2c In-Office/Video, In -Home, or Community with Transportation: 4.2d FTM, TDM, Prof. Staffing: 4.2e No show: 4.2f Mileage rate: $ Amount 160 175 n/a 160 120 0.65 Unit Type Select Unit Type. Select Unit Type. Select Unit Type. per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included in rate: 60 60 miles miles This is paid after the miles listed above. 4.3 Hourly Service #3 Name: I Group Psychotherapy REV. OCT 2021 3 ATTACHMENT C - PROPOSAL 4.3a In-Office/Video: 4.3b In -Home or Community: 4.3c In-Office/Video, In -Home, or Community with Transportation: 4.3d FTM, TOM, Prof. Staffing: 4.3e No show: 4.3f Mileage rate: $ Amount 50 n/a n/a 160 50 n/a Unit Type Select Unit Type. Select Unit Type. Select Unit Type. per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included in rate: n/a n/a miles miles This is paid after the miles listed above. 4.4 Hourly Service #4 Name: 4.4a In-Office/Video: 4.4b In -Home or Community: 4.4c In-Office/Video, In -Home, or Community with Transportation: 4.4d FTM, TDM, Prof. Staffing: 4.4e No show: 4.4f Mileage rate: $ Amount Unit Type Select Unit Type. Select Unit Type. Select Unit Type. per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included in rate: miles miles This is paid after the miles listed above. 4.5 Hourly Service #5 Name: 4.5a 4.5b 4.5c 4.5d 4.5e 4.5f In-Office/Video: In -Home or Community: In-Office/Video, In -Home, or Community with Transportation: FTM, TDM, Prof. Staffing: No show: Mileage rate: $ Amount Unit Type Select Unit Type. Select Unit Type. Select Unit Type. per Hour per No Show per Mile No. of roundtrip miles included in rate: No. of roundtrip miles included in rate: This is paid after the miles listed above. miles miles 4.6 Monthly Service Rates (each level must be listed): I Service Name with - Level Rate Month per Minimum Service: Hours of 4.6a ♦ - I 4.6b I 4.6c . 1 4.6d 4.6e 4.6f 4.6g I 4.6h y 4.6i 4.6j 4.7 Home Study Providers - List your rates in the box below. M,ntmum 4.8 Monitored Sobriety Providers — List your rates in the box below. REV. OCT 2021 4 ATTACHMENT C o PROPOSAL Provider special notes l Jeremy Sharp, PhD Director 1/19/23 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: Ha Hay ley le ew Lewis Jeremy T. Sharp, PhD, LLC dba Colorado Center for Assessment and Counseling PHONE NUMBER: 970-480-7361 EMAIL: info@coloradocac.com PROPOSED SERVICE(S): Neuropsychological Evaluation, Individual Psychotherapy,Group Ps chothera Psychotherapy, � Substance Use Evaluation Legal Last Name Initial Middle Previous Name (If applicable) Legal Last Legal First Name Service Type Licensure/ Credentials DORA # (If applicable) Hill Aaron ividual Psychother LCSW, LAC CSW.09925100, ACD.0001075 Ranson Alyssa atherapy & Substa LPC, LAC LPC.0018065 ACD.0001879 Reckling Anne uropsych. Evaluati PsyD PSY.0005304 Alvarado Andrea (August) 1 Evaluation & Psyc PhD PSY.0005283 Mondo Colleen arospsych. Evaluat PhD PSY.0004632 Kontz Emily Psychotherapy , LCSW CSW.09926688 Lazo Geneane ial & Group Psycho LPC LPC.0016067 Sharp Jeremy uropsych. Evaluati PhD PSY.3349 Perry Joselyne uropsych. Evaluati_ PhD PSY.4564 Piccoli Kathleen :uropsych. Evaluati PsyD PSY.6030 Gonynor Kelly Jai & Group Psycho LMFT MFT.0001709 Leggiadro Elizabeth (Liz) uropsych. Evaluati PsyD PSY.5550 Jaramillo Matt Indiv. & Group I PhD PSY.5188 Brinker Michael +►al, 'uropsych Evaluati PsyD PSY.4656 Denmark Miriam roup Psychotheraf LCSW LSW.0009926528 McLaren Molly ividual Psychother PhD PSY.4339 Gladstone Pete uropsych. Evaluati PhD PSY.5620 Hoke Rebecca jai & Group Psycho LCSW CSW.09925802 r Jeremy Sharp, PhD Director 1/19/23 CHILD WELFARE REQUEST FOR PROPOSAL 2023-24 - VARIOUS SERVICES ACS RO? CERTIFICATE OF LIABILITY INSURANCE oaizorzoz3' 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(les) 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 Trust Risk Management Services, Inc. doing business in CO as Potomac Risk Management Services, Inc. 1791 Paysphere Circle Chicago, IL 60674 CONTACT NAME: Trust Risk Management Services, Inc PHONE F% IAIC, No, Eat,: 877.637.9700I IA/C, Nol: 877.251.5111 EMAIL ADDRESS: info.nustims.com INSURER. AFFORDING COVERAGE INSURER A: ACE American Insurance Company NAIL N 22667 INSURED Jeremy Sharp 3500 John F Kennedy Pkwy Ste 200 Fort Collins, CO 80525 2635 INSURER B: 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 Arm Waal INSR WVD POLICY NUMBER POLICY E. (MMroDNYVY) POLICY EXP (MMIDDNYYY1 LIMITS COMMERCIAL GENERAL LIABILITY 'CLAIMS MADE i IOCCUR C_1 EACH OCCURRENCE $ DAMAGES(TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) S PERSONAL 8 ADV INJURY I GEML AGGREGATE LIMIT APPLIES PER: PRO- POLICY C�JECT �LOC OTHER: GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ AUTOMOBILE _ LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED _~ AUTOS U70SED COMBINED SINGLE LIMIT (Ea accident) S BODILY INJURY (Per Person) $ BODILY INJURY (Per accidenll PROPERTY DAMAGE (Per accident) $ S UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE $ DEO I 'RETENTIONS S ENIs.COMPENSATION =EN AND EMPLOYERS LIABILITY ANY N R ,WE'Z'P'xITLM /EXECUTIVE YIN OFFICERlMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Ni A (STATUTE I IERH EL.EACH ACCIDENT S E.L. DISEASE -EA EMPLOYEE $ EL. DISEASE - POLICY LIMIT S Psychologist's Professional A Liability Retroactive Date: 04/01/2009 Y 58622792581 04/01/2023 04/01/2024 Each Incident Annual Aggregate $1,000,000 $3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required,: CERTIFICATE HOLDER CANCELLATION Additional Insured Board of County Commissioners of Weld County and its Officers/ Employees 1150 O St 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. AUTTHHORIIZEDD REPRESENTATIVE ACORD 25 (2016/03) O1968-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SIGNATURE REQUESTED: Weld/CO Ctr for Assmt and Counseling (Jeremy Sharp PhD) PSA Final Audit Report 2023-05-11 Created: 2023-05-10 By: Windy Luna (wluna@co.weld.co.us) Status: Signed Transaction ID: CBJCHBCAABAAS02ygdmgyeSPbZHEPUZtZdAwNtpXyOHN "SIGNATURE REQUESTED: Weld/CO Ctr for Assmt and Couns eling (Jeremy Sharp PhD) PSA" History t Document created by Windy Luna (wluna@co.weld.co.us) 2023-05-10 - 7:25:16 PM GMT E Document emailed to dr.sharp@coloradocac.com for signature 2023-05-10 - 7:26:15 PM GMT ,n Email viewed by dr.sharp@coloradocac.com 2023-05-11 - 10:16:25 PM GMT 4, Signer dr.sharp@coloradocac.com entered name at signing as Jeremy Sharp 2023-05-11 - 10:17:40 PM GMT 2So Document e -signed by Jeremy Sharp (dr.sharp@coloradocac.com) Signature Date: 2023-05-11 -10:17:42 PM GMT - Time Source: server Q Agreement completed. 2023-05-11 - 10:17:42 PM GMT vewered Dy Adobe Acrobat Sign Contract Form Entity Name. SHARP, JEREMY Entity ID* O00017001 ❑ New Entity? Contract Marne. Contract ID SHARP, JEREMY DBA COLORADO CENTER FOR ASSESSMENT 6997 AND COUNSELING (NEW BID #62300{40 - PROFESSIONAL SERVICES AGREEMENT) Contract Status CTB REVIEW Contract Lead* WLUNA Contract ract Lead Email w1 u naoveidgov. com;cobbx xlk@weldgov.com Parent Contract ID Requires Board Approval YES Department Project Contract Description. (CONSENT) SHARP, JEREMY DBA COLORADO CENTER FOR ASSESSMENT AND COUNSELING (NEW BID #62300040 - PROFESSIONAL SERVICES AGREEMENT). (NEW BID #B2300040 - PROFESSIONAL SERVICES AGREEMENT). TERM 06/01/2023 THROUGH 05/31/2024. Contract Description 2 PROVIDER WAS LISTED ON APPROVED PROVIDER VENDOR UST PRESENTED TO THE BOCC ON 03/29,23 AND AS A COMMUNICATION ITEM/PA SENT TO CTB ON 03/ 30/2023. Contract Type* AGREEMENT Amount* $0.00 Renevvabl YES Automatic Renewal Department HUMAN SERVICES Department Email CM- HumanServices eldgov.co Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COU NTYATTORNEY@WELDG OV.COM Requested BOCC Agenda Date* 05/24;2023 Due Date 05/20/2023 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 Con Contact Info Contact Name Pu rcltasinq Purchasing Approver Approval Process Department Head JAMIE ULRlCH DH Approved Date 05;1512023 Final 1pprca BOCC Approved BOCC Signed Date BOCC Agenda Date 05;2212023 Originator WLUNA Review Date* 03=2912024 Committed Delivery Date Contact Type Contact Email Finance Approver CHERYL PATTELLI Renewal Date* 05:3112024 Expiration Date Contact Phone 1 Purchasing Approved Date Finance Approved Date 05,17/2023 Tyler Ref # AG 052223 Legal Counsel BYR0N HOWELL Contact Phone 2 Legal Counsel Approved Date 05/18/2023 Hello