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Home My WebLink About20211439.tiffCortvcc+ IDwosli PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 28, 2023 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2021-22 Core/Non-Core Contracted Services B2100042 Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement Amendments for 2021-22 Core/Non-Core Contracted Services B2100042. The Department entered into Agreements with various Child Welfare Service Providers through the 2021-22 Request for Proposal (RFP), Bid Number: B2100042, identified as Tyler ID 2021-0307. These Agreements were issued for a period of three (3) years with the option to renew annually. The Department is requesting to renew the current Agreements with no changes for twelve (12) Providers reflected in the attached list. Agreements will be renewed for the third and final year, for the period of June 1, 2023 through May 31, 2024. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed Agreement Amendments will be obtained from Providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. I recommend approval of these Agreement Amendments and authorize the Chair to sign. Approve Recommendation Perry L. Buck, Pro -Tern Mike Freeman, Chair Scott K. James Kevin D. Ross Lori Saine Schedule Work Session Pass -Around Memorandum; Marc�,'20��VIri us' Coma+ 4/02/-7723 Q/z /23 Other/Comments: Page 1 ZOZ i439 e -12-00q3 PRIVILEGED AND CONFIDENTIAL Cl � NAME Ell # BID -- YEAR , TYLER ID Behavior Services of the Rockies _ B2100042 2021-22 2021-1581 __ Centennial Mental Health Center, Inc. B2100042 2021-22 2021-1579 Colorado State University B2100042 2021-22 2021-1583 Jcnes, Dr. Jacob B2100042 2021-22 2021-1470 N xrthern Horizon Behavioral Health - Nikki Tolle B2100042 2021-22 2021-1436 Reaching Hope B2100042 2021-22 2021-1547 Reece, Alison B2100042 2021-22 2021-1438 -)1(--- Sovereicgnty_Counselinq - Annette Brown B2100042 2021-22 2021-1439 Specialty Counseling & Consuiti _r_ _ B2100042 2021-22 2021-1466 The Hope Initiative B2100042 2021-22 2021-1582 Vi- alCare B2100042 2021-22 2021-1469 W.thers Whisper - Andrea Hall B2100042 2021-22 2021-1471 Pass-Arounc I ternorandum; March 28, 2023 — CMS ID Various Page 2 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND SOVEREIGNTY COUNSELING SERVICES, PLLC This Agreement Amendment, made and entered into Z(0 th day of 1 ( , 2023 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 Sovereignty Counseling Services, PLLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Foster Care/Adoption Support, Therapeutic Kinship Support, Life Skills, and Mental Health Services, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021- 1439, approved on May 26, 2021. 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, 2022. • The Original Agreement was amended on: • May 2, 2022 to extend the term date through May 31, 2023. • This Amendment is identified by the Weld County Clerk to the Board of County Commissioners as document number 2021-1439. • 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: 1. Term This agreement is being renewed for the third and final year, for the period of June 1, 2023 through May 31, 2024. • All other terms and conditions of the Original Agreement remain unchanged. 20,21, /x,39 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTEST - BY: ddrifm) Jeico;&k. COUNTY: BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Deputy Cler Ito the Bo. /��►' - - ike Freeman, Chair "per. cjiviV NTRACTOR: APR 2 6 2023 overeignty Counseling Services, PLLC 2580 East Harmony Road, Suite 201 Fort Collins, Colorado 80528 Annette 3'rown By: Annette Br own (Apt 14, 2023 18:50 MDT) Annette Brown, Owner/Therapist Apr 14, 2023 Date: O02//L1L3 9 SIGNATURE REQUESTED: Weld/Sovereignty Amendment #2 2023-24 Final Audit Report 2023-04-15 Created: 2023-04-14 By: Windy Luna (wluna@co.weld.co.us) Status: Signed Transaction ID: CBJCHBCAABAAhT10Azu0VvxOsaHLSCLcdTUJjzQXhrML "SIGNATURE REQUESTED: Weld/Sovereignty Amendment #2 2023-24" History t Document created by Windy Luna (wluna@co.weld.co.us) 2023-04-14 - 8:47:33 PM GMT -► Document emailed to Annette Brown (annette@sovereigntycounseling.com) for signature 2023-04-14 - 8:48:15 PM GMT r5 Email viewed by Annette Brown (annette@sovereigntycounseling.com) 2023-04-15 - 0:49:29 AM GMT f0". Document e -signed by Annette Brown (annette@sovereigntycounseling.com) Signature Date: 2023-04-15 - 0:50:36 AM GMT - Time Source: server d Agreement completed. 2023-04-15 - 0:50:36 AM GMT Names and email addresses are entered into the Acrobat Sign service by Acrobat Sign users and are unverified unless otherwise noted. Dowered by Adobe Acrobat Sign Contract Form CoI Entity Name' Entity ID' SOVEREIGNTY COUNSELING SERVICES #00042283 PLLC ❑ New Entity? Contract Name* Contract ID SOVERIEGNTY COUNSELING SERVICES PLLC (BID .B2100042) 6855 (CHILD PROTECTION AGRMT AMENDMENT #2) Contract Status CTB REVIEW Contract Lead' WLUNA Contract Lead Entail wluna' weldgov.com;cobbx xlkioiweldgov.com Parent Contract ID 20211439 Requires Board Approval YES Department Project it Contract Description* (CONSENT) SOVERIEGNTY COUNSELING SERVICES, PLLC (CHILD PROTECTION AGREEMENT AMENDMENT #2). TERM: 06101/2023 THROUGH 05/31/2024. Contract Description 2 PROVIDER WAS LISTED ON APPROVED VENDOR UST PRESENTED TO THE BOCC ON 03/28/2023 AND AS A COMMUNICATION ITEM /PA SENT TO CTB ON 03/30/2023. Contract Type* AGREEMENT Amount' 50.00 Renewable* NO Automatic Renewal Department HUMAN SERVICES Department Email CM- HurnanServices@weldgov.co Department Head Email CM-HumanServices- De ptHeadweldgov.co m County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORN EYC#WELDG OV.COM Requested BOCC Agenda Date' 04/26/2023 Due Date 04122/2023 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 NSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnRase Contract Dates Effective Date Termination Notice Period Conta Contact fn Contact Name Purchasing ion Review Date. 03129;2024 Committed Delivery Date Contact Type Contact Email Renewal Date Expiration Date* 05/31;2024 Contact Phone 1 Contact Phone 2 Purchasing Approver Purchasing Approved Date Approval Process Department Head JAMIE ULRICH DH Approved Date 04,17/2023 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 04;26,2023 Originator WLUNA Finance Approver CHERYL PATTELLI Legal Counsel BYRON HOWELL Finance Approved Date Legal Counsel Approved Date 04/18/2023 04/18/2023 Tyler Ref f AG 042623 Con4-ve&c,+ 1 b 5i i i PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 29, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2021-22 Core/Non-Core Contracted Services B2100042 Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement Amendments for 2021- 22 Core/Non-Core Contracted Services B2100042. The Department entered into Agreements with various Child Welfare service providers through the 2021-2022 Request for Proposal (RFP), Bid Number: B2100042, identified as Tyler ID 2021-0307. These Agreements were issued for a period of three (3) years with the option to renew annually. The Department is requesting to renew the current Agreements with no changes for sixteen (16) providers reflected in the attached list. Agreements will be renewed for the second year for the period of June 1, 2022 through May 31, 2023. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed Agreement Amendments will be obtained from providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. I recommend approval of these Agreement Amendments and authorize the Chair to sign. Perry L. Buck Mike Freeman, Pro -Tern Scott K. James, Chair Steve Moreno Lori Saine Approve Recommendation 6pail Schedule Work Session Other/Comments: Pass -Around Memorandum; March 29, 2022 - CMS ID — Various Page 1 CoYISe,(vt- fte,nola. 05/ OZ,/Z ec;671,6,-4-(4-1‘D) ,502/aa ZeV-IX13°1 1410_0095 PRIVILEGED AND CONFIDENTIAL CMS Name Behavior Services of the Rockies Bid # B2100042 Bid Year 2021-22 Tyler ID 2021-1581 Centennial Mental Health B2100042 2021-22 2021-1579 Colorado State University B2100042 2021-22 2021-1583 Hartshorn, Mandee dba Creative Nursing LLC B2100042 2021-22 2021-1437 Jones, Dr. Jacob B2100042 2021-22 2021-1470 Northern Colorado Counseling (Rascon, Christina) B2100042 2021-22 2021-1467 Northern Horizon Behavioral Health - Nikki Tolle B2100042 2021-22 2021-1436 Reaching Hope B2100042 2021-22 2021-1547 Reece, Alison B2100042 2021-22 2021-1438 Rocky Mountain Kids B2100042 2021-22 2021-1465 Sovereignty Counseling - Annette Brown 62100042 2021-22 2021-1439 Specialty Counseling & Consulting B2100042 2021-22 2021-1466 The Hope initiative 62100042 2021-22 2021-1582 Tindall and Associates B2100042 2021-22 2021-1606 VitalCare B2100042 2021-22 2021-1469 Withers Whisper -Andrea Hall B2100042 2021-22 2021-1471 Pass -Around Memorandum; March 29, 2022 - CMS ID — Various Page 2 Karla Ford From: Sent: To: Subject: yes Lori Saine Weld County Commissioner, District 3 1150 0 Street PO Box 758 Greeley CO 80632 Phone: 970-400-4205 Fax: 970-336-7233 Email: Isaine@welcigov.com Website: www.co.weld.co.us In God We Trust Lori Saine Tuesday, March 29, 2022 11:34 AM Karla Ford RE: Please Reply - PA FOR ROUTING: CW Core Non -Core 2021-22 Renewals B2100042 (CMS Various) Confidentiality Notice: 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: Karla Ford <kford@weldgov.com> Sent: Tuesday, March 29, 2022 10:45 AM To: Lori Saine <Isaine@weldgov.com> Subject: Please Reply - PA FOR ROUTING: CW Core Non -Core 2021-22 Renewals B2100042 (CMS Various) Importance: High Please advise if you approve recommendation. Thank you! Karla Ford Y Executive Assistant & Office Manager, Board of Weld County Commissioners 1150 0 Street, P,O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kford@weldgov.com:: www.weldgov,com :: **Please note my working hours are Monday -Thursday 7:00a.m.-5:00p.m.** 1 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND SOVEREIGNTY COUNSELING SERVICES, PLLC This Agreement Amendment, made and entered into L day of tA. , 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Se ces, hereinafter referred to as the "Department", and Sovereignty Counseling Services, PLLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Foster Care/Adoption Support, Therapeutic Kinship Support, Life Skills, and Mental Health Services, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1439, approved on May 26, 2021. 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, 2022. • This Amendment, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for the second year, for the period of June 1, 2022 through May 31, 2023. • 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: BOARD OF COUNTY COMMISSIONERS WELL OUNTY, COLORADO BY: Deputy Clerk K. James, Chair MAY 0 2 2022 Sovereignty Counseling Services, PLLC 2580 East Harmony Road, Suite 201 Fort Collins, Colorado 80528 By: Annette Brown 21, 2022 0912 MDT) Annette Brown, Owner/Therapist Date: Apr 21, 2022 029AI -/i71,59 Contract Form Entity Information New Contract Request Entity Name* Entity ID* SOVEREIGNTY COUNSELING SERVICES `0i0042283 PLLC Contract Names SOVEREIGNTY COUNSELING SERVICES PLLC (AGREEMENT AMENDMENT PY 2022-23) Contract Status CTB REVIEW Contract Description* BID# B2100042. TERM 6 1 22-5;`31 23, Contract Description 2 CONSENT: PA WAS SENT TO CTB ON: 3'30 2022. Contract Type* AMENDMENT Amount* $0.00 Renewable* NO Automatic Renewal Grant ICA Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.co 'Ti Department Head Email CM-HumanServices- DeptHeadgweldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY WELDG OV.COM If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID ❑ New Entity? Contract ID 5777 Contract Lead* APEGG Contract Lead Email apegggzlweldgov.com ,co bbx xlkgiweldgov.com Requested BOCC Agenda Date* 05,`25;'2022 Parent Contract ID 20211439 Requires Board Approval YES Department Project # Due Date 05;21.2022 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 On Base Contract Dates Effective Date Review Date* 04;'03 2023 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 04;'22,+2022 Final Approval BOCC Approved BOCC Signed Date BOCC Agent 05'0212022 Originator APEGG e Contact Type Committed Delivery Date Contact Email Finance Approver CONSENT Expiration Date* 05:31=2023 Contact Phone 1 Purchasing Approved Date 04(22;'2022 Finance Approved Date 04/22:2022 Tyler Ref ;# AG 050222 Legal Counsel CONSENT Contact Phone 2 Legal Counsel Approved Date 04;22:2022 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND SOVEREIGNTY COUNSELING SERVICES, PLLC 1-14 This Agreement, made and entered into th day of 2021, by and between the Board of Weld County Commissioners, on behalf of the Weld County Depart nt of Human Services, hereinafter referred to as the "Department' and Sovereignty Counseling Services, PLLC, ereinafter referred to as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule. Exhibit B, C, and D are attached hereto and incorporated herein by this reference. Exhibit A is Weld County's Request for Proposal Number B2100042 which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to the Department for Foster Care/Adoption Support, Therapeutic Kinship Support, Life Skills, and Mental Health Services. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 2021, upon proper execution of this Agreement and shall expire May 31, 2022, unless sooner terminated as provided herein. The agreement is for a period of three years. However, the agreement must be renewed by both parties, in writing, on an annual basis. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit B, Contractor's Response to Request for Proposal and Exhibit C, Scope of Services. 3. Referrals, Billing and Tracking a. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e- mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Quality Assurance Team (HS-CWOualitvAssurance(a,weldsov.com). No other Department staff or other party to the case may authorize services or modifications to services. c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation by the 7th of the month, following the month of service, utilizing billing forms required by the Department. Contractor agrees to utilize the Client Verification Form for all scheduled and unscheduled face-to-face services with the exception of home studies and monitored sobriety testing. e4: oit14,401,59 2021-1439 Pleooq0- Contractor agrees that original complete Client Verification Forms are to be submitted with the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet 60 -day deadline may result in termination of the Agreement. d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service, for each client receiving ongoing services. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Date and time of service b. Where the service took place c. Clinician/therapist name d. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will be the test result. A completed home study may be a full, partial or denied study, as determined by the Department. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. 4. Payment a. The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: i. The service being provided by the contractor is not a Medicaid eligible service; ii. The service is not deemed medically necessary; iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; iv. A Medicaid provider is not available to provide the needed service; v. Medicaid is exhausted for the needed service; or vi. Medicaid denied service. vii. The client is not eligible for Medicaid. b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule, attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent upon, the continuing availability of said funds for the purposes hereof. d. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 2 5. 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 OMG Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule: a. If services are funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. b. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and - Title VII of the Civil Rights Act of 1964; and - the Age Discrimination in Employment Act of 1967; and the Equal Pay Act of 1963; and - the Education Amendments of 1972; and - Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and 3 - all regulations applicable to these laws prohibiting discrimination because of race, color, national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, Contractor and the Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any all Federal and/or State financial assistance. - Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, contractors and sub -contractors. b. Contractor is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the United States Department of Health and Human Services, Office for Civil Rights. c. Contractor assures that it will fully comply with all other applicable Federal and State laws which may govern the ability of the Department to comply with the relevant funding requirements. Contractor understands the source of funds to be accessed under the Agreement is determined by the Department. d. Contractor assures and certifies that it and its principals: - Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a Federal or State department or agency; and - have not, within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; and - are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state or local) with commission of any of the offenses enumerated in this certification; and - have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, or local) terminated for cause or default. e. Public Contracts for Services C.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this contract. Contractor will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E - Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5- 102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to undertake pre -employment screening or job applicants while this Agreement is being performed. If Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is 4 employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contractor shall not terminate the contract if within three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. shall comply with reasonable requests made in the course of an investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and Employment. If Contractor participates in the State of Colorado program, Contractor shall, within twenty days after hiring a new employee to perform work under the contract, affirm that Contractor has examined the legal work status of such employee, retained file copies of the documents, and not altered or falsified the identification documents for such employees. Contractor shall deliver to the Department, a written notarized affirmation that it has examined the legal work status of such employee and shall comply with all of the other requirements of the State of Colorado program. If Contractor fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq., the Department, may terminate this Agreement for breach, and if so terminated, Contractor shall be liable for actual and consequential damages. f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if Contractor receives federal or state funds under the contract, Contractor must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the contract. If Contractor operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24- 76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. § 24-76.5- 103 prior to the effective date of the contract. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 3(d) of this Agreement. 9. Insurance Requirements Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Contractor shall provide the liability insurances (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged in the performance of this Agreement which are required under Weld County's Request for Proposal, and required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the acceptable evidence that such coverage is in effect within seven (7) days of the date of this Agreement. At a minimum, Contractor shall procure, either personally or through its employer as applicable to the Contractor's business, at its own expense, and maintain for the duration of the work, insurance coverage 5 listed in this agreement. The Board of County Commissioners of Weld County and its Officers/Employees shall be named as additional insured. a. General Requirements: Contractors must secure, at or before the time of execution of any agreement or commencement of any work, the following insurance covering all operations, goods or services provided pursuant to this request. Contractors shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, and during any warranty period. The required insurance shall be underwritten by an insurer licensed to do business in Colorado and rated by A.M. Best Company as "A"VIII or better. Each policy shall contain a valid provision or endorsement stating "Should any of the above -described policies by canceled or should any coverage be reduced before the expiration date thereof, the issuing company shall send written notice to the Weld County Director of General Services by certified mail, return receipt requested. Such written notice shall be sent thirty (30) days prior to such cancellation or reduction unless due to non-payment of premiums for which notice shall be sent ten (10) days prior. If any policy is in excess of a deductible or self -insured retention, the Department must be notified by the Contractor. Contractor shall be responsible for the payment of any deductible or self -insured retention. The Department reserves the right to require Contractor to provide a bond, at no cost to the Department, in the amount of the deductible or self -insured retention to guarantee payment of claims. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. Contractor shall maintain, at its own expense, any additional kinds or amounts of insurance that it may deem necessary to cover its obligations and liabilities under this Agreement. b. Types of Insurance: Contractor shall obtain, and maintain at all times during the term of any Agreement, insurance in the following kinds and amounts: i.Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance covering all of Contractor's employees acting within the course and scope of their employment. If Contractor is an Independent Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93 or equivalent, covering premises operations, fire damage, independent Contractors, products and completed operations, blanket contractual liability, personal injury, and advertising liability with minimum limits as follows: - $1,000,000 each occurrence; - $2,000,000 general aggregate; - $50,000 any one fire; and - $500,000 errors and omissions. iii.Automobile Liability: Contractor shall maintain limits of $1,000,000 for bodily injury per person, $1,000,000 for bodily injury for each accident, and $1,000,000 for property damage applicable to all vehicles operating both on County property and elsewhere. iv.Additional Provisions: Policies for all general liability, excess/umbrella liability, liquor liability and pollution liability must provide the following: If any aggregate limit is reduced by twenty-five percent (25%) or more by paid or reserved claims, Contractor shall notify the Department within ten (10) days and reinstate the aggregates required; Unlimited defense costs in excess of policy limits; Contractual liability covering the indemnification provisions of this Agreement; A severability of interests provision; Waiver of exclusion for lawsuits by one insured against another; 6 A provision that coverage is primary; and A provision that coverage is non-contributory with other coverage or self-insurance provided by the Department. v.For all general liability, excess/umbrella liability, liquor liability, pollution liability and professional liability policies, if the policy is a claims -made policy, the retroactive date must be on or before the contract date or the first date when any goods or services were provided to the Department, whichever is earlier. c. Contractors shall secure and deliver to County's Risk Administrator ("Administrator") at or before the time of execution of this Agreement, and shall keep in force at all times during the term of the Agreement as the same may be extended as herein provided, a commercial general liability insurance policy, including public liability and property damage, in form and company acceptable to and approved by said Administrator, covering all operations hereunder set forth in the related Bid or Request for Proposal. d. Proof of Insurance: Contractor shall provide a copy of this information to its insurance agent or broker and shall have its agent or broker provide proof of Contractor's required insurance. The Department reserves the right to require Contractor to provide a certificate of insurance, a policy, or other proof of insurance as required by the County's Risk Administrator in his sole discretion. e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal liability, liquor liability, and inland marine, Contractor's insurer shall name County as an additional insured. f. Waiver of Subrogation: For all coverages, Contractor's insurer shall waive subrogation rights against County. g. Subcontractors: All subcontractors, independent contractors, sub -vendors, suppliers or other entities providing goods or services required by this Agreement shall be subject to all of the requirements herein and shall procure and maintain the same coverages required of Contractor. Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers or other entities as insureds under its policies or shall ensure that all subcontractors maintain the required coverages. Contractor agrees to provide proof of insurance for all such subcontractors, independent contractors, sub -vendors, suppliers or other entities upon request by the Department. A provider of Professional Services (as defined in the Bid or RFP) shall provide the following coverage: Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and $2,000,000 aggregate limit for all claims. 10. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 7 12. 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. 13. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: - Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. - Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. - Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives 8 of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s). For Department: Heather Walker, Child Welfare Director 17. Notice For Contractor: Annette Brown, Owner/Therapist All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich, Director P.O. Box A Greeley, Colorado 80632 (970) 400-6510 18. Litigation For Contractor: Annette Brown, Owner/Therapist 2580 East harmony Road, Suite 201 Fort Collins, Colorado 80528 (970) 964-3133 Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department, or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third -Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The 9 parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties/Conflict of Interest No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department when the Contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the two relationships are in opposition. During the term of the Agreement, Contractor shall not enter into any third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall 10 be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. Contractor shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality requirements. Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, and as set forth in Exhibit A, provide proof thereof when requested to do so by County. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner 11 consistent with the professional standards governing such services and the provisions of this Agreement. The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence and judgment provided by highly competent individuals and entities that perform services of a similar nature to those described in this Agreement including Exhibits A, B, C, and D. 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to the Department originals of all tests and results, reports, etc., generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. §&24-18-201 et seq. and &24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 34. Choice of Law/Jurisdiction Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 36. Attorney's Fees/Legal Costs 12 In the event of a dispute between the Department and Contractor, concerning this Agreement, the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf. 37. Ownership All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of the Department. In addition, all reports, documents, data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the Department. Contractor shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of the Department. 38. Interruptions Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. 39. Severability If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: /• .z+go;11 Weld Cou p Clerk to the Board By: Deputy Clerk to th=['. oard 13 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Steve Moreno, Chair CONTRACTOR: MAY 2 6 2021 Sovereignty Counseling Services, PLLC 2580 East Harmony Road, Suite 201 Fort Collins, Colorado 80528 (970) 964-3133 By: Date: Annette May 19, 202111:22 EDT) Annette Brown, Owner/Therapist May 19, 2021 tea`t EXHIBIT A 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 intentionally left blank. Exhibit B Contractor's response to the Request for Proposal Exhibit B contains the following documents: • Attachment B — Provider Information Form (PIF) • Attachment C — Proposal • Attachment D — Staff Data Sheet • Certificate of Insurance (COI) EXHIBIT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES - PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION Agency Name: Sovereignty Counseling Services, PLLC Provider Contact Full Name: Annette Brown Trails Provider ID (if known): Title: Owner/Therapist Primary Phone Number (10 -digit): 970-964-3133 Ext.: Fax Number (10 -digit): Primary Contact Email: annette@sovereigntycounseling.com Web Address: sovereigntycounseling.com Agency Location Address (street, city, state, zip): 2580 E. Harmony Rd. ste. 201 Ft. Collins, CO 80528 Agency Mailing Address (Street, city, state, zip): 2580 E. Harmony Rd. Ste. 201 Ft. Collins, CO 80528 Agency Type (pick one): 17 Public Company Private Non -Profit Private for Profit Referral Contact Name: Send Referrals for Service to: Annette Brown Referral Phone Number (10 -digit): 970-964-3133 Ext.: Title: Owner/Therapist Email: annette@sovereigntycounseling.com Billing Contact Billing Contact Name: Annette Brown Billing Phone Number (10 -digit): 970-964-3133 Ext.: Email: Title: Owner/Therapist annette@sovereigntycounseling.com CERTIFICATION II certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the I 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. IThe Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to accept the bid, or part of a bid, that, in the opinion of the Board, is in the best interests of the Board and of the County of Weld, State of Colorado. The Board of Weld County Commissioners shall give preference to resident Weld County bidders in all cases where the bids are competitive in price and quality. Authorized Rep. Full Name: Annette Brown Title: Owner/Therapist Authorized Rep. Email: annette@sovereigntycounseling.com Phone (10 -digit): 970-964-3133 Ext.: 2580 E. Harmony Rd. ste. 201 Ft. Collins, CO 80528 Authorized Rep. Address (Street, city, state, zip): I Signature of Authorized Rep.: Date REV. NOVEMBER 2020 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Annette Brown Program Area: Foster Parent Training Number of services offered on this Attachment C (max 5): Program Areas are listed in column 1 of the table located in Item XI of the You may complete another Attachment C if you have more than S. Request for Proposal starting on page 13. 1 SECTI t N 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: Foster Parent Training 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): ® Psychoeducation 2.1b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 90-120 minutes/training 2.1c Anticipated duration of service (i.e. 3-4 months): 1-12 per year 2.1d Three (3), or more, specific goals of the service (DO use bullet points): Prepare/Support foster parents in providing nurturing care in a safe and healthy environment. • Prepare/Support foster parents in meeting the developmental and emotional needs of the children. • Develop skills in trauma informed parenting skills • Develop/Promote skills in protecting and promoting the child's cultural identity and heritage. • Develop/promote child's connection to his or her own family as appropriate. 2.1e Three (3), or more, specific outcomes of service: REV. NOV 2020 1 ATTACHMENT C - PROPOSAL Ongoing preparation and support for foster parents in meeting the needs of children who have been abused and neglected. Increased ability to address trauma response behaviors in foster children effectively and compassionately. ® Competent and compassionate foster parents who provide care in a safe and healthy environments within Weld County. 2.1f Target population of the service, including age and gender: • Prospective and current foster parents within the Department of Human Services in Weld County Colorado. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: No Service #2 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company hist :pry; DO use bullet points): 2a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 2b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 2c 2. Three (3), or more, specific goals of the service (DO use bullet points): 2d 2. Three (3), or more, specific outcomes of service: 2e 2. Target population of the service: 2f 2. Languages service is available in (please list proficiency and if interpreter services are available): 2g REV. NOV 2020 2 TT s: zC ',` ENT C ® PRPSa'��"�L 2. Medicaid eligibility list whether the service is eligible for Medicaid in whole or in part: 2h Service #3 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 3a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 3b administrative time, overhead, or travel time (he. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (Le. 34 months): 3c 2. Three (3), or more, specific goals of the service (D 3d * use bullet points): 2. Three (3), or more, specific outcomes of service: 3e 2. Target population of the service: 3f 2. Languages service is available in (please list proficiency and if interpreter sere ices are available): 3g 2. Medicaid eligibility — list whether the service is eligiblJ for Medicaid hi wh 3h le or hi part: Service #4 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company hist••ry; DO use bullet points): 4a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 4b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: REV. NOV 2020 3 ATTACHMENT C - PROPOSAL 2. Anticipated duration of service (i.e. 3-4 months): 4c 2. Three (3), or more, specific goals of the service (DO use bullet points): 4d 2. Three (3), or more, specific outcomes of service: 4e 2. Target population of the service: 4f 2. Languages service is available in (please list proficiency and if interpreter services are available): 4g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 4h Service #5 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 5a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 5b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 5c 2. Three (3), or more, specific goals of the service (DO use bullet points): 5d 2. Three (3), or more, specific outcomes of service: 5e 2. Target population of the service: 5f REV. NOV 2020 4 i eTT C H Sy > < 2. Languages service is available in (please list proficiency and if interpreter servic 5g s are available): 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part 5h Section 3 e Service Access an • Transport on 3. Will y charge Weld County for transporting clients or mileage? Check .,ne: X YES 1 3. Will you cnduct services hi a client's home or the community? Check one: 2 3. Will you transport clients to and/or from services? Check one: 3 3. How many miles are y 4 NO X YES NO YES `:`.b NO u willing to traell round trip? List a specific number of miles. 50 Miles 3. When you calculate mileage, what is your starting point address? 5 2980 E. Harmony Rd. Ste. 201 Fort Collins, CO 80528 or 6730 Coach Light Ct. Timnath, CO 80547 All rates need t SECTION ® 5ErtVICE '?t tit RTES include administrative work (i.e. scheduling or report 1.1 rating) and overhead. Rates cannot b _n e isode except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted f r services, except for those listed above. For hourly rates complete section(s) 41�4QSa For monthly rates complete section 406. For Home study providrs c mpOete section 427. F monit:.red s brietY% testhir providers co plete section 4.8. REV. NOV 2020 5 ATTACHMENT C - PROPOSAL Hourly Service #1 Name: Foster Parent Training $ Amount Unit Type 4.1a In-Office/Video: 4.1b In -Office with Transportation: In -Home or Community: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate: 180 per Hour 0 per Hour 200 per Hour 0 per Hour 95 per No Show 0.50 per Mile No. of miles included in rate: No. of miles included in rate: 0 50 This is paid after the miles listed above. miles miles 4. Hourly Service #2 Name: 2 4.2a In-Office/Video: 4.2b In -Office with Transportation: 4.2c In -Home or Community: 4.2d FTM, TDM, Prof. Staffing: 4.2e No show: 4.2f Mileage rate: $Amount Unit Type per Hour per Hour per Hour per Hour per No Show per Mile N o. of miles included in rate: N o. of miles included in rate: This is paid after the miles listed above. miles miles 4. Hourly Service #3 Name: 3 4.3a In-Office/Vide:: 4.3b In -Office with Transportation: 4.3c In -Home or Community: 4.3d FTM, TDM, Prof. Staffing: 4.3e No show: 4.3f Mileage rate: $ Amount Unit Type per Hour per Hour per Hour per Hour per No Show per Mile N o. of miles included in rate: N o. :•:f miles included in rate: This is paid after the miles listed above. miles miles REV. NOV 2020 6 ATTACHMENT C - PROPOSAL 4. Hourly Service 4 4.4a 4.4b In -Office 4.4c 4.4d 4.4e #4 Name: In-Office/Video: with In -Home FTM, TDM, Transportation: or Community: Prof. Mileage Staffing: No show: rate: $ Amount Unit Type per Hour per Hour per Hour per Hour per No per Mile Show No. No. This of miles included of miles included is paid after in in the miles rate: rate: listed miles miles above. 4. Hourly Service 5 4.5a 4.5b In 4.5c 4.5d 4.5e 4.5f #5 -Office FTM, Name: In -Home In-Office/Video: with Transportation: or TDM, Community: Prof. Staffing: No show: Mileage rate: $ Amount Unit per Hour per Hour per Hour per Hour per No per Mile Type No. No. Show This of miles of miles is paid included in rate: included in rate: after the miles listed miles miles . above. 4. 6 Monthly Service Rates (each level must be listed): Service Name with Level Rate per Month No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d 4.6e 4.6f REV. NOV 2020 ATTACHMENT C - PROPOSAL 4.6g 4.6h 4.6i 4.6j 4. Home Study Providers — List your rates in the box below. 7 4. Monitored Sobriety Providers — List your rates in the box below. 8 Provider special notes: REV. NOV 2020 8 ATTACHMENT C® PROP SAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider an Progra Bidders Legal Name: Annette Brown Program Area: Foster Parent Cons action rre Area Information Number of services offered on this Attachment C (max 5): Program Areas are listed in column 1 of the table located in Item XI of the You may complete another Attachment C if you have more than 5. Request for Proposal starting on page 11 1 i SECTION 2 — Service Name(s) and Information If the service is a m nthlackage, please offer different levels.monthly packages must stto a s eci c minimum number of direct service hours. Service #1 Name: Kinship services 2.1a Modalities, curriculum, t= •:ls used in delivery sf service (DO NOT list company history; DO use bullet points): Psychoeducation Strategic therapy to address family interaction and effective communication. Therapeutic Games and Homework assignments Incredible Years skills/principles (for foster parents of children 3-7 years old) Reality Therapy Systemic -Attachment Informed E;MIDR 2.1b 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: 2-6 hours/week 2.1c Anticipated duration of service (i.e. 3-4 months): 1-6 months, as needed 2.14 Three (3), or more, specific goals of the service (DO use bullet points): • To minimize the traumatic effects on the children) being removed their home or previous placement. ® To develop foster environments capable of responding to the "whole child", including emotional and behavioral needs of neglected and abused children. ® To provide education and support to foster parents. 2.1e Three (3), or more, specific outcomes of service: REV. NOV 2020 1 ATTACHMENT C - PROPOSAL • Reduced effects of trauma on the child(ren) who have been removed from their home or previous placement. Competent and confident foster parents capable of responding to the "whole child" including the emotional and behavioral needs of neglected and abused children. • Foster parents with foundational knowledge regarding trauma, abuse and neglect, transitions, mental health system navigation, reunification, and baseline information about developmentally appropriate expectations and behaviors within the context of child welfare. 2.1f Target population of the service, including age and gender: ® Foster home households and families with children ages birth to 17 years -old, who are receiving co- occurring services (such as families with children in out -of -home placement who are referred through the family court system to therapeutic or supportive interventions) from the local department of Human services. 1 English speaking participants and families, unless interpreter is provided by Weld County. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NO Service #2 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 2b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 2c 2. Three (3), or more, specific goals of the service (DO use bullet points): 2d 2. Three (3), or more, specific outcomes of service: 2e 2. Target population of the service: 2f REV. NOV 2020 2 ATTACHMENT C ® PR POSAL 2. Languages service is available in (please list proficiency and if interpreter services are available): 2g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2h Service #3 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 3a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 3b administrative time, overhead, or travel time (he. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (Le. 341 months): 3c 2. Three (3), or more, specific gals of the service (O use bullet points): 3d 2. Three (3), or more, specific outcomes 3e f service: 2. Target p.pulation of the service: 3f 2. Languages service is available in (please list prficiency and if interpreter services are available): 3g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 3h Service #4 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 4a REV. NOV 2020 3 ATTACHMENT C - PROPOSAL 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 4b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 4c 2. Three (3), or more, specific goals of the service (DO use bullet points): 4d 2. Three (3), or more, specific outcomes of service: 4e 2. Target population of the service: 4f 2. Languages service is available in (please list proficiency and if interpreter services are available): 4g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 4h Service #5 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 5a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 5b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 5c 2. Three (3), or more, specific goals of the service (DO use bullet points): 5d 2. Three (3), or more, specific outcomes of service: 5e REV. NOV 2020 4 ATTACHMENT C m PROPOSAL 2e Target population of the service: 5f 2. Languages service is available in (please list pry: ficiency and if interpreter services are available): 5g 2e Medicaid eligibility — list wheth 5h r9 t h e s rvice is eligible for Medicaid in whole or in part Section 3 Service Access and Transportation 3. Will you charge Weld County f r transporting clients or mileag Check one: X YES ❑ NO 30 Will you coduct services in a clients h.• me ,,r in the c_•irnmunity? Check one: 2 3. Will you transport clients to and/ err from services? Check 3 ,) X YES ❑ NO ne: YES X 3. How many miles are y willing to travel round trip? List a specific number f miles. 50 Miles 4 3. Wh an you calculate mileage, what is your start 5 gp int address? 2580 E Harmony Rd, Fort Collins, CO 80522 or 6730 Coach Light Ct. Timnath, CO 80547 SECTI t:_a._ TES All rates need to include administrative work (1e0 scheduling or report writing) and overhead. Rates cannot be per episode, excel t for h ;ime studies and monitored sobriety testing. Only hourly }r monthly rates will be accepted for services, except for those listed above. F hourly rates complete secti n(s) 4.1-45. For m . nthly rates complete secti. n 4.6. For H me study pr viders complete section 4e7e r y For monitored sobriety testing providers complete section 4.8. REV. N .:f;V 2020 5 ff is / '. ENT mY r, > I 4. Hourly Service #1 Name: 1 4.1a Foster Parent Consultation In-Office/Video: $ Amount Unit Type 110 40Th In -Office with Transportation: 0 In -Home or Community: 4.1c FTM, TDM, Pr: f. Staffing: 4.1d 4.1e 160 65 No sh w: 95 Mileage rate: 0.50 per Hour per Hour per Hour per Hour per N I.J Show per Mile miles included in rate: 0 No.: if miles included in rate: 30 This is paid after the miles listed abveo miles miles 4m Hourly Service #2 Name: 2 4.2a 4o2b In -O'' ice with Transportation: 4.2c 4.2d 4.2e N •; show: 4.2f In-Office/Video: In-H4me :•;r C Immunity: FTM, TDM, Prof. Staffing: Mileage rate: $ Amount Unit Type per Hour per Hour per Hour per H u r per N t Sh w per Mile No. of miles included in rate: No. of miles included in rate: This is paid after the miles listed ab ve. miles miles 4. Hourly Service #3 Name: 3 4.3a In-Office/Video: 403b In -Office with Transportation: 4.3c In -Home or Community: 4.3d FTM, TDM, Prof. Staffing: 4.3e No show: $ Amount Unit Type per H ur per Hour per Hour per Hour per No Show N :•,a of miles included in rate: No. f miles included in rate: miles miles REV. NOV 2020 6 ATTACHMENT C - PROPOSAL 4.3f Mileage rate: per Mile This is paid after the miles listed above. 4. 4 Hourly 4.4b 4.4d 4.4e 4.4a 4.4c Service In -Office #4 In FTM, Name: -Home with TDM, In-Office/Video: Transportation: or Community: Prof. Mileage No Staffing: show: r rate: $ Amount Unit per per per per per per Hour Hour Hour Hour No Mile Type Show No. No. This of of is miles miles paid included included after the in in miles rate: rate: listed miles miles above. 4. 5 Hourly 4.5a 405b 4.5c 4.5d 4.5e 4.5f Service In #5 -Office FTM, Name: In -Home with TDM, In-Office/Video: Transportation: or Prof. Mileage Community: No Staffing: show: rate: Amount Unit per per per per per per Hour Hour Hour Hour No Mile Type Show No. No. This of of is miles miles paid included included after the in in miles rate: rate: listed miles miles above. 4. 6 Monthly Service Rates (each level must be listed): Service Name with Level Rate Month per No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d REV. NOV 2020 7 ATTACHMENT C - PROPOSAL 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4. 7 Home Study Providers — List your rates in the box below. 4. 8 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: REV. NOV 2020 8 ATTACHMENT C ® PROPOSAL Please type yur answers in the boxes below or check the appropriate box. Bidder's Legal Name: Program Area: SECTI rove er and Program a Information Annette Brown foster Parent Consultation Number of services offered on this Attachment C (max 5): Program Areas are listed in column 1 of the table located in Item XI of the You may complete another Attachment C if you have more than S. Request for Proposal starting on page 13. 1 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: kinship Services 2.1a Modalities, curriculum, to Is used in delivery of service (DO NOT list company history; DO use bullet p:• ints): Psychoeducation Strategic therapy to address family interaction and effective communication. Therapeutic Games and Homework assignments Incredible Years skills/principles (for foster parents of children 3-7 years old) Reality Therapy Systemic -Attachment Informed EMDR 2.1b 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: 2-6 2.1c Anticipated duration service (Leo 3-4 mss nths): 1-6 months, as needed 2.1d Three (3), or more, specific goals of the service (DO use bullet points): To minimize the traumatic effects on the children) being removed their home or previous placement. To develop foster environments capable of responding to the "whole child", including emotional and behavioral needs of neglected and abused children. To provide education and support to foster parents. 2.1e Three (3), or more, specific outcomes of service: REV. NOV 2020 1 ATTACHMENT C - PROPOSAL • Reduced effects of trauma on the child(ren) who have been removed from their home or previous placement. • Competent and confident foster parents capable of responding to the "whole child" including the emotional and behavioral needs of neglected and abused children. • Foster parents with foundational knowledge regarding trauma, abuse and neglect, transitions, mental health system navigation, reunification, and baseline information about developmentally appropriate expectations and behaviors within the context of child welfare. 2.1f Target population of the service, including age and gender: • Kinship care households and families with children ages birth to 17 years -old, who are receiving co- occurring services (such as families with children in out -of -home placement who are referred through the family court system to therapeutic or supportive interventions) from the local department of Human services. • English speaking participants and families, unless interpreter is provided by Weld County. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NO Service #2 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 2b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 2c 2. Three (3), or more, specific goals of the service (DO use bullet points): 2d 2. Three (3), or more, specific outcomes of service: 2e 2. Target population of the service: 2f REV. NOV 2020 2 ATT CH TC- PROP SAL 2. Languages service is available in (please list proficiency and if interpreter services are available): 2g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2h Service #3 Name: 20 Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 3a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 3b administrative time, overhead, or travel time (i.e. 4 hours/week). if the service has levels, be specific for each level: 20 Anticipated duration of service (i.e. 3-4 months): 3c 2. Three (3), or more, specific g 3d als of the service (DO use bullet points): 2. Three (3), or more, specific outcomes of service: 3e 20 Target population of the service: 3f 2. Languages service is available in (please list proficiency and if interpreter services are available): 3g 20 Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 3h Service #4 Name: 20 Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 4a -14 REV. NOV 2020 3 ATTACHMENT C ® P '' } ,,_ SAL 2. Anticipated frequency of direct service time with the client/family per week, not including pr= fessional staffing time,. 4b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 4c 2. Three (3), or mare, specific goals of the service (DO use bullet pints): 4d 2. Three (3), or rm s re, specific outcomes .• f service: 4e 2. Target p: pulation 4f ft> f the service: 2. Languages service is available in (please list proficiency and if interpreter services are available): 4g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 4h Service #5 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 5a 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 5b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for =ach lel: 2.. Anticipated durati f service (It. 3-4 months): 5c 2. Three (3), or mre, specific goals •:f the service (DO use bullet points): Sd 2. Three (3), or more, specific outc•*mes of service: Se REV. NOV 2020 4 ATTACHMENT C - PROPOSAL 2. Target population of the service: 5f 2. Languages service is available in (please list proficiency and if interpreter services are available): 5g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part 5h Section 3 — Service Access and Transportation 3. Will you charge Weld County for transporting clients or mileage? Check one: X YES 1 3. Will you conduct services in a client's home or in the community? Check one: 2 3. Will y uu transport clients to and/or from services? Check 3 X YES ne: YES X 3. How many miles are you willing to travel round trip? List a specific number of miles. 50 Miles 4 NO NO 3. When you calculate mileage, what is your starting point address? 2580 E Harmony Rd, Fort Collins, CO 80528 or 5 6730 Coach Light Ct. Timnath, CO 80547 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) 4,3-4.5. For monthly rates complete section 4.6. For Home study providers complete section 4.7. For monitored sobriety testing providers complete section 4.8. REV. NOV 2020 5 ATTACHMENT C Sr. �. L 4. Hourly Service 1 Name: 1 4.1a Foster Parent Consultation In-Office/Video: 4.1b In -Office with Transportation: In -Home or Community: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1. Mileage rate: $ Amount Unit Type 110 0 160 65 95 030 per Hour per Hour p r Hour per Hour per No Show per Mile N o.:sf miles included in rate: No. of ; .ales included in rate: O 30 This is paid after the miles listed above. miles miles 4. Hourly Service #2 Name: 2 4.2a In-Office/Video: 402b In -Office with Transportation: tic In -Home or Community: 4.2d 4.2e 4.2f FTM, TDM, Prfe Staffing: No show: Mileage rate: $ Amount Unit Type per Hour per Hour per Hour per Hour per No Show per Mile N 0 .f miles included in rate: No. of miles included in rate: This is paid after the miles listed above. miles miles 4e Hourly Service #3 Name: 3 4.3a In-Office/Video: 4.3b In -Office with Transportation: 4.3c In -Home Community: 4.3d FTM, TDM, Prof. Staffing: 4.3e No show: $ Amount Unit Type per Hour per Hur per Hour per Hour per No Show No. f miles included in rate: No. of miles included in rate: miles miles REV. NOV 2020 6 ATTACHMENT C o PROPOSAL 4.3f Mileage rate: per Mile This is paid after the miles listed above. 4. 4 Hourly 404b 4.4d 4.4e 4.4a 4.4c Service In -Office #4 In FTM, Name: -Home with TOM, In-Office/Video: Transportation: or Community: Prof. Mileage No Staffing: show: rate: $ Amount Unit per per per per per per Hour Hour Hour Hour No Mile Type Show This No. of No. of is miles miles paid included included after the in in miles rate: rate: listed miles miles above. 4. 5 Hourly 4.5a 4.5b 4.5c 4.5d 4.5e 4.5f Service In #5 -Office FTM, Name: In -Home with TOM, In-Office/Video: Transportation: or Prof. Community: Mileage No Staffing: show: rate: $ Amount Unit per per per per per per Hour Hour Hour Hour No Mile Type Show No. No. This of of is miles miles paid included included after the in in miles rate: rate: listed miles miles above. 4. 6 Monthly Service Rates (each level must be listed): Service Name with Level Rate Month per No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d REV. NOV 2020 7 ATTACHMENT C - PROPOSAL 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4. Home Study Providers — List your rates in the box below. 7 4. Monitored Sobriety Providers — List your rates in the box below. 8 Provider special notes: REV. NOV 2020 8 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Annette Brown Program Area: Number of services offered on this Attachment C (max 5): Program Areas are listed in column 1 of the table located in Item XI of the You may complete another Attachment C if you have more than S. Request for Proposal starting on page 13. 2 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: Supervised Visitation 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): ® Strength Based, Present -focused feedback e Psychoeducation • Incredible Years skills/principles (for parents of children 3-7 years old) 2.1b 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: 0-4 2.1c Anticipated duration of service (i.e. 3-4 months): 1-6 months; as needed; as court ordered 2.1d Three (3), or more, specific goals of the service (DO use bullet points): • To increase knowledge of parenting skills and capability to provide for children's needs including appropriate discipline, child empathy and developmental stages with in the moment feedback and modeling to correct parenting techniques during visitation. e To provide references and link families to additional services when necessary to meet children's special physical and mental needs e To increase parent/child bonding ® To illicit measurable growth in regard to parenting skills 2.1e Three (3), or more, specific outcomes of service: REV. NOV 2020 1 ATTACH ME T C ® PROPOS L • Established, maintained or strengthened family relationships Enhanced well-being of child(ren) and reduced trauma/effects of separation Increased parenting skills and confidence to provide for children's needs Measurable increased growth in regard to parenting skills 2.1f Target population of the service, including age and gender: Families with children in out -of -home placement who are referred through the Family Courts for parent - child visitation from the local department of human services with visitation needs in Larimer County. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English 20t Medicaid eligibility — list wheth t. r the service is eligible for Medicaid in whole ring rt: No Service #2 Name: Therapeutic Visitation 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2a X41 Strategic Therapy Principles Psychoeducation Therapeutic Games & Homework Strength Based, Present -focused feedback Incredible Years skills/principles (for parents of children 3-7 years old) 2. Anticipated frequency if direct service time with the client/family per week, not including professional staffing time, 2b administrative time, overh -°ad, :r travel time (i.e. 4 hours/week). If the service has levels, be specific f. r each level: 04 20 Anticipated duration of service (i.e. 34 months): 2c 1-6 months; as needed; as court ordered 2. Three (3), or more, specific goals of the service (DO use bullet points): 2d To provide a safe, welcoming environment to hasten the reunification process To increase parent/child bonding To increase knowledge of appropriate parenting skills and capability to provide for children's needs To provide references and link families to additional services when necessary to meet children's special physical and mental need ® To provide therapeutic intervention and address barriers in parent/child relationship 2. Three (3), or more, specific outcomes of service: 2e REV. NOV 2020 2 ATTACHMENT C - PROPOSAL Established, maintained or strengthened family relationships ® Enhanced well-being of children) and reduced trauma/effects of separation Increased parenting skills and confidence to provide for children's needs Measurable increased growth in regard to parenting skills Barriers to parent/child relationship addressed/resolved 20 Target population of the service: 2f Families with children in out -of -home placement who are referred through the Family Courts for parent - child visitation from the local department of human services with visitation needs in Larimer County. 2. Languages service is available in (please list proficiency and if interpreter services are available): 2g English 2. M 2h dicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: No Service #3 Name: 2. Modalities, curriculum, to 3a (�J Is used in delivery of service (DO NOT list company history; DO use bullet points): 2e Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 3b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 3c 2. Three (3), or more, specific gals of the service (DO use bullet points): 3d 2. Three (3), or more, specific outcomes of service: 3e 2. Target population of the service: 3f 2a Languages service is available in (please list proficiency and if interpreter services are available): 3g REV. NOV 2020 3 CH E .4I1 T C ® P PS L 2. Medicaid eligibility — list whether the service is eligible for Medicaid in hole r in part: 3h Service #4 Name: 2. Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 4a 2. Anticipated frequency tf direct service time with the client/family per week, not including professional staffing time, 4b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 4c 2e Three (3), or more, specific goals of the service (DO use bullet points): 4d 2. Three (3), or more, specific outcomes of service: 4e 2. Target population of the service: 4f 2. Languages s-trvice is available in (please list proficiency and if interpreter services are available): 4g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 4h Service #5 ,',w►, one: 20 odalies, curriculum, to 5a 1\ l.. Is used in delivery . f service (DNOT list company history; DO use bullet points): 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 5b administrative time, overhead, or travel time (i.e. 4 h urs/week). If the service has levels, be specific for each level: REV. NOV 2020 4 ATTACHMENT C ® PROPOSAL 2. Anticipated duration of service (i.e. 3-4 rm: nths): Sc 2. Three (3), or more, specific goals of the service (DO use bullet points): 5d • 2. Three (3), or more, specific outc Se 2. Target population of the service: Sf mes of service: 2. Languages service is available in (please list proficiency and if interpreter services are available): 5g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part 5h Section 3 = Service Access and Transportation 3. Will you charge Weld Cunty f: r transporting clients or mileage? Check one: X YES 1 NO 3. Will you conduct services hi a clients home ,r in the community? Check one: X YES NO 2 3. Will you transport clients to and/or from services? Check one: ❑ YES X NO 3 3. How many miles are you willing to travel round trip? List a specific number of miles. 50 Miles 4 3. When you calculate mileage, what is your starting point address? 2980 E. Harmony Rd. Ste. 201 Fort Collins, CO 80528 or 5 6730 Coach Light Ct. Timnath, CO 80547 REV. NOV 2020 5 ATT ',.C E T C Pt c , L SECTIO 4 -SE All rates need to include administrative work (i.e. scheduling or report writing) and overhead. Rates cannot be per episodes except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except for those listed above. F he ,s...rly rates complete section(s) 4.1-4.5. For monthlrates complete sr-rc or 4.6. For Home study providers complete section 4.7. For m Y itor d s briety testing providers comp) ne sects at 4. Hourly Service #1 t,.. e: 1 Supervised Visitation 4.1a f ice/Vide®: 4a1b In -Office with Transp rtation: In -Home or Community: 4.1c FTM, T®M® Prof. Staffing: 4.1d 4.1e N •y show: Mileage rate: $ Am _•punt Unit Type 65 0 95 65 95 030 per Hur per Hour per Hour per Hour per No Show per Mile No. of miles included hi rate: No. of miles included in rate: 0 50 This is paid after the miles listed above. miles miles 4. Hourly Service #2 Name: 2 4.2a Therapeutic Visitation ffice/Video: 402b In -Office with Transportation: 4.2c In -Home or Community: 4.2d 4.2e 4.2f FTM, T®Mg Prof. Staffing: N; show: Mileage rate: $ Amount Unit Type 90 0 135 95 030 per Hour per Hour per Hour per Hour per No Shw per Mile No. of miles included in rate: Nof miles included in rate: 0 50 This is paid ,fter the miles listed above. miles miles REV. NOV 2020 6 ATT ,,CH T C= PR POSAL 4. Hourly Service #3 Name: 3 4.3a 403b 4.3c 403d 4©3e 4.3f In-Office/Video: In -Office with Transportation: In -Home or Community: FTM, TDM, Prof. St: ding: No sh WV: Mileage rate: Unit Type per Hour per Hour per Hour per Hour per lid is: Show per Mile N o. of miles included in rate: N o. of miles included in rate: This is paid after the miles listed above. miles miles 4. Hourly Service #4 Name: 4 4.4a In-Office/Video: 4m4b hi -Office with Transportation: hi -Home or C mmunity: 404c FTMg TDMB Prof Staffing: 404d No show: 4.4e Mileage rate: $ Amount Unit Type per Hour per Hour per Hour per Hour per No Show per Mile N o. of miles included in rate: N o.: f miles included in rate: This is paid after the miles listed above. miles miles 4. Hourly Service #5 Name: 5 405a In-Office/Video: 4e5b In -Office with Transportation: 4.5c 4.5d 4.5e 4.5f in -H me or Crmmunity: FTM, T F M, Pr fa Staffing: No show: Mileage rate: Amount Unit Type per Hour per Hour per Hour per Hour per No Show per Mile N o. of miles included in rate: N of miles included in rate: This is paid after the miles listed above. miles miles REV. NOV 2020 7 ATTACHMENT C - PROPOSAL 4. Monthly Service Rates (each 6 level must be listed): Service Name with Level Rate per Month No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.6i 4.6j 4. Home Study Providers — 7 List your rates in the box below. 4. Monitored Sobriety 8 Providers — List your rates in the box below. Provider special notes: REV. NOV 2020 8 ATTACHMENT C - PROPOSAL Please type your answers in the boxes below or check the appropriate box. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Annette Brown Program Area: Mental Health Services Number of services offered on this Attachment C (max 5): Program Areas are listed in column 1 of the table located in Item XI of the You may complete another Attachment C if you have more than 5. Request for Proposal starting on page 13. 2 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: Individual Therapy 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): • EMIT • CBT • Motivational Interviewing Psychoeducation • Mindfulness • Therapeutic Homework 2.1b 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: 2-8 hours/week 2.1c Anticipated duration of service (i.e. 3-4 months): 3-6 months; as needed; court ordered 2.1d Three (3), or more, specific goals of the service (DO use bullet points): REV. NOV 2020 1 ATTACHMENT C - PROPOSAL To provide diagnostic and/or therapeutic services To improve the client's mental health, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. ® Address client welfare specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resiliency ® Reprocess maladaptive neuropathways consequences of loss, grief, abuse and neglect to increase adaptive and resilient responses. ® To decrease or eliminate psychological and somatic suffering do to maladaptive memory storage of sexual trauma To reprocess maladaptive neuropathways related to sexual trauma ® To increasing adaptive response and regulation to triggers related to trauma Lie Three (3), r more, specific outcomes f service: Improved client mental health and impacts of mental health. Client mental health needs addressed related to loss, grief, abuse, neglect, and assist in building resiliency ® Client accesses adaptive neuropathways to utilize in regulating emotions and response to life stress and triggers related to experienced trauma. Decreased/Eliminated suffering related to sexual trauma Increased adaptive ability to respond to triggers and life stress 2.1f Target population of the service, including age and gender: Individuals 3+ years old experiencing mental health symptoms due to trauma related loss, grief, abuse, neglect, and assist in building resiliency, receiving co-occurring services (including individuals in out -of -home placement who are referred through family courts) form the local department of human services. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole * r in part Yes Service #2 Name: Family Therapy 2. Modalities, curriculum, to Is used in delivery of service (DI) r\I T list company history; DO use bullet points): 2a Multisystemic Therapy Theory EMDR CBT Mindfulness Psychoeducation Therapeutic Homework REV. NOV 2020 2 ATTACHMENT C - PROPOSAL 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, 2b administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2-6 hours/week 2. Anticipated duration of service (i.e. 3-4 months): 2c 3-6 months; as needed; court ordered 2. Three (3), or more, specific goals of the service (DO use bullet points): 2d • To provide diagnostic and/or therapeutic services to assist in the development of family services plan ® To assess and/or improve family communication, functioning and relationships. • To improve the family or dyad's mental health and or relationship, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. ® Explore family welfare specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resiliency ® Reprocess maladaptive neuropathways consequences of loss, grief, abuse and neglect to increase adaptive and resilient responses. 2. Three (3), or more, specific outcomes of service: 2e ® Improved mental health in family members and impacts of mental health. ® Family member's mental health needs addressed related to loss, grief, abuse, neglect, and assist in building resiliency ® Family members can access adaptive neuropathways to utilize in regulating emotions and response to life stress and triggers related to experienced trauma. ® Improved family communication, functioning and relationships. 2. Target population of the service: 2f Family dyads or groups with children 0-18 years old experiencing mental health symptoms due to trauma related loss, grief, abuse, neglect, and assist in building resiliency, receiving co-occurring services (including individuals in out -of -home placement who are referred through family courts) form the local department of human services. 2. Languages service is available in (please list proficiency and if interpreter services are available): 2g English 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 2h Yes Service #3 Name: REV. NOV 2020 3 TTACH ENT C 2. Modalities, curriculum, t•;ols used in delivery l:f service 0 NOT list company history; DO use bullet points): 3a 2. Anticipated frequency of direct service time with the client/family per week, not including prfessional staffing time, 3b administrative time, overhead, s :r travel time (Le. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration ref service (i.e. 3a4 months): 3c 2. Three (3), or more, specific goals 3d f the service (DO use bullet p 2. Three (3), or more, specific outcmes of service: 3e 2e Target population of the service: 3f ints): 2. Languages service is available in (please list proficiency and if interpreter services are available): 3g 2. Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: 3h Service #4 Name: 2. Modalities, curriculum, toIs used in delivery of service (DO NOT list company history; 4a 2. Anticipated frequency of direct s y1•1 use bullet points): rvice timwith the client/family per we k, not including pro•fessitn staffing tie, 4b administrative time, overhead, :• r travel time (Le. 4 hours/week). If the service has levels, be specific for each lev-l: 2e Anticipated durati n , ,f service (Le. 3-4 ni=nths): 4c 2. Three (3), or rn 4d r sp cific g s of the service (DO use bullet points): REV. NOV 2020 4 ATTACH '-A =: ENT C ® PR P SAL 2. Three (3), or more, specific outcomes of service: 4e 2. Target population of the service: 4f 2. Languages service is available in (please list proficiency and if interpreter services are available): 4g 2. Medicaid eligibility list hether the service is eligible for Medicaid in whole or in part: 4h Service #5 Name: 2. Modalities, curriculum, tick used in delivery of service (DO NOT list company history; DO use bullet points): Sa 2. Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, Sb administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2. Anticipated duration of service (i.e. 3-4 months): 5c 2e Three (3), •::r more, specific goals of the service (DO use bullet points): 5d 2. Three (3), or more, specific Se utcomes of service: 2e Target population of the service: Sf 2. Languages service is available in (please list proficiency and if interpreter services are available): 5g 2. Medicaid eligibility v list whether the service is eligible for Medicaid in whole or in part 5h REV. NOV 2020 5 TTn., d CH ETC—P Section 3 rg Service (mess a 3. Will you charge Weld County for transp+rng clients or mileage? Check one: 1 rt Ii YES NO 3. Will you conduct services in a client's home or in the cmmunity? Chck one: YES 2 3. Will y4 u transport clients to and/or from services? Check •one: [ l YES 3 3. How many miles are you willing to travel round trip? List a specific number f miles. 50 Miles 4 3. When you calculate mileage, what is your starting point address? 5 2580 E. Harmony Rd. Fort Collins, CO 80528 or 6730 Cach Light Court Timnath, CO 80547 ,11 SECTION 4 - SERVICE "Ai All rates need to include administrative work (Le. schedule .� _p :r re rt riting) and overheads Rates cannot be per episode, except for home studies -nd :: onitored s}•>>briety testing. Only hourly or monthly rates will be accepted for services, except for the se listed ab ® For hourly rates comtlete section(s) 4.1-43. F4 -r monthly rates complete section 4 Fir Hme stuy prYMiders ct mplet seal For monitored s briety tesdn proidekts c '-V J f�3 r t 4.7. mplete secti 4 m a Hourly Service #1 Name: Individual Therapy 4a1a In-Office/Video: 4a1b In -Office with Transportati lncH me or Community: $ Amount Unit Type 120 0 180 per Hour per Hour ION f miles included in rate: per H•ur No. of miles included in rate: 0 50 miles miles REV. NOV 2020 6 ATTACHMENT C m PROPOSAL 4.1c 4.1d 4.1e FTM, TDM, Pr f£ Staffing: No show: 65 95 Mileage rate: 0.50 per H•ur per No Show per Mile This is paid after the miles listed above. 4. Hourly Service #2 Name: 2 4.2a Family Therapy In-Office/Vid 4e2b In -Office with Transportation: 4.2c In -Home or Community: 4.2d FTM, TDM, Pr ,fe Staffing: 4.2e No show: 4.2f Mileage rate: $ Amount Unit Type 120 0 180 65 95 0.50 per Hour per Hour per Hour per Hour per No Show per Mile No. of miles included in rate: No. of miles included in rate: 0 This is paid after the miles listed above. miles miles 4. Hourly Service #3 Name: 3 4.33 In-Office/Video: 4.3b In -Office with Transportation: 4.3c In -Home or Community: 4.3d FTM, TDM, Prof. Staffing: 4.3e No show: 4.3f Mileage rate: $ Amount Unit Type per Hour per Hour per Hur per Hour per No Show per Mile No. of miles included in rate: No.f miles included in rate: This is paid after the miles listed above. miles miles 4. Hourly Service #4 Name: 4 4.4a In-Office/Video: 4.4b In -Office with Transportation: $ Amount Unit Type per Hour per Hour N•a of miles included in rate: miles REV. NOV 2020 7 ATTACHMENT C - PROPOSAL In 4.4c FTM, 4.4d 4.4e -Home or Community: TDM, Prof. Mileage Staffing: No show: rate: per Hour No. per Hour per No Show per Mile This of is miles included in rate: paid after the miles listed miles above. 4. 5 Hourly 4.5a 4.5b 4.5c 4.5d 4.5e 4.5f Service #5 In -Office Name: with In -Home FTM, TDM, In-Office/Video: Transportation: or Prof. Community: Staffing: No show: Mileage rate: $ Amount Unit per Hour per Hour per Hour per Hour per No per Mile Type No. of miles No. of miles Show This is paid included included after in rate: in rate: the miles listed miles miles above. 4. 6 Monthly Service Rates (each level must be listed): Service Name with Level Rate Month per No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.6i I 4.6j REV. NOV 2020 8 ATTACHMENT C - PROPOSAL 4. Home Study Providers — List your rates in the box below. 7 4. Monitored Sobriety Providers — List your rates in the box below. 8 Provider special notes: REV. NOV 2020 9 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): Annette Leann Brown AGENCY CONTACT:Annette Brown PHONE NUMBER: 97®-96403133 EMAIL: annette@sovereigntycounseling.com PROPOSED SERVICE(S): Mental Health Services, Life Skills, Kinship Services, Foster Parent Consultation, Foster Parent Training Leal Last Name Brown Brown Middle Initial L L Previous Legal Last Name (If applicable) Riedman Riedman Annette Annette Therapist Life Skills l icensure/ Credentials MFTC MFTC DORA # (If applicable) MFTC.0013902 MFTC.0013902 CHILD WELFARE REQUEST FOR PROPOSAL 2021-22 - VARIOUS SERVICES BID NO. B2100042 C^ ARb® A l�VR CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 03/17/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Affinity Insurance Service, Inc. 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034-3278 CONTACT Lynette Smith PHONE 1-888-288-3534 FAX (A/C. Ext): (NC, No): MAIL ADDRESS: customer.service@hpsocover.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: American Casualty Company of Reading, PA 20427 INSURED Sovereignty Counseling Service 2580 E Harmony Rd Ste 201 Fort Collins, CO, 80528 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 LTRINSD TYPE OF INSURANCE ADDL SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PRO- JECT PER: LOC PRODUCTS-COMP/OPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/ N N IA PER STATUTE ERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Professional Liability x 684409943 03/31/2021 03/31/2022 Liability (Each claim): $1,000,000 Liability (Aggregate): $3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Board of County Commissioners of Weld County and it's Officers / Employees are added as an Additional Insured to the Professional Liability effective 3/31/2021, per the policies terms and conditions. CERTIFICATE HOLDER CANCELLATION Weld County 1150 O Street 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 EXHIBIT C SCOPE OF SERVICES Contractor will provide Foster Care/Adoption Support, Therapeutic Kinship Support, Life Skills, and Mental Health Services, as referred by the Department. 1. Foster Parent Training a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Psychoeducation b. Anticipated Frequency of Services: i. Ninety (90) to 120 minutes per training. c. Anticipated Duration of Services: i. One (1) to 12 times a year. d. Goals of Services: i. Prepare and support foster parents in providing nurturing care in a safe and healthy environment. ii. Prepare and support foster parents in meeting the developmental and emotional needs of the children. iii. Develop skills in trauma informed parenting skills. iv. Develop and promote skills in protecting and promoting the child's cultural identity and heritage. v. Develop and promote the child's connection to his or her own family as appropriate. e. Outcomes of Services: i. Ongoing preparation and support for foster parents in meeting the needs of children who have been abused and neglected. ii. Increased ability to address trauma response behaviors in foster children effectively and compassionately. iii. Competent and compassionate foster parents who provide care in a safe and healthy environment. f. Target Population: i. Prospective and current foster parents within the Department. g. Language: i. English h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor will conduct services in the client's home or in the community. ii. Contractor is willing to travel up to 50 miles roundtrip from one of two addresses: 1. 2980 East Harmony Road, Suite 201, Fort Collins, Colorado 80528 2. 6730 Coach Light Court, Timnath, Colorado 80547 2. Kinship Services a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Psychoeducation. 1 ii. Strategic therapy to address family interaction and effective communication. iii. Therapeutic Games and Homework assignments. iv. Incredible Years skills/principles for foster parents of children ages three (3) to seven (7). v. Reality Therapy. vi. Systemic -Attachment Informed Eye Movement Desensitization and reprocessing (EMDR). b. Anticipated Frequency of Services: i. Two (2) to six (6) hours per week. c. Anticipated Duration of Services: i. One (1) to six (6) months as needed. d. Goals of Services: i. To minimize the traumatic effects on the child(ren) being removed their home or previous placement. ii. To develop foster environments capable of responding to the "whole child", including emotional and behavioral needs of neglected and abused children. iii. To provide education and support to foster parents. e. Outcomes of Services: i. Reduced effects of trauma on the child(ren) who have been removed from their home or previous placement. ii. Competent and confident foster parents capable of responding to the "whole child" including the emotional and behavioral needs of neglected and abused children. iii. Foster parents with foundational knowledge regarding trauma, abuse and neglect, transitions, mental health system navigation, reunification, and baseline information about developmentally appropriate expectations and behaviors within the context of child welfare. f. Target Population: i. Foster home households and families with children ages birth to age 17, who are receiving co-occurring services (such as families with children in out -of -home placement who are referred through the family court system to therapeutic or supportive interventions) with the Department. g. Language: i. English h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor will conduct services in the client's home or in the community. ii. Contractor is willing to travel up to 50 miles roundtrip from one of two addresses: 1. 2980 East Harmony Road, Suite 201, Fort Collins, Colorado 80528 2. 6730 Coach Light Court, Timnath, Colorado 80547 3. Supervised Visitation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Strength based present -focused feedback. ii. Psychoeducation. iii. Incredible Years skills/principles for foster parents of children ages three (3) to seven (7). b. Anticipated Frequency of Services: 2 i. Up to four (4) hours per week. c. Anticipated Duration of Services: i. One (1) to six (6) months as needed or court ordered. d. Goals of Services: i. To increase knowledge of parenting skills and capability to provide for children's needs including appropriate discipline, child empathy and developmental stages within the moment feedback and modeling to correct parenting techniques during visitation. ii. To provide references and link families to additional services when necessary to meet children's special physical and mental needs. iii. To increase parent/child bonding. iv. To illicit measurable growth regarding parenting skills. e. Outcomes of Services: i. Established, maintained, or strengthened family relationships. ii. Enhanced well-being of child(ren) and reduced trauma/effects of separation. iii. Increased parenting skills and confidence to provide for children's needs. iv. Measurable increased growth regarding parenting skills. f. Target Population: i. Families with children in out -of -home placement who are referred through the Family Courts for parent -child visitation from the Department with visitation needs in Weld County. g. Language: i. English h. Medicaid Eligibility: i. This service is not Medicaid eligible. Service Access and Transportation: i. Contractor will conduct services in the client's home or in the community. ii. Contractor is willing to travel up to 50 miles roundtrip from one of two addresses: 1. 2980 East Harmony Road, Suite 201, Fort Collins, Colorado 80528 2. 6730 Coach Light Court, Timnath, Colorado 80547 4. Therapeutic Visitation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Strategic Therapy Principles ii. Psychoeducation iii. Therapeutic Games and Homework iv. Strength Based, Present -focused feedback v. Incredible Years skills/principles for foster parents of children ages three (3) to seven (7). b. Anticipated Frequency of Services: i. Up to four (4) hours per week. c. Anticipated Duration of Services: i. One (1) to six (6) months as needed or court ordered. d. Goals of Services: i. To provide a safe, welcoming environment to hasten the reunification process. 3 ii. To increase parent/child bonding. iii. To increase knowledge of appropriate parenting skills and capability to provide for children's needs. iv. To provide references and link families to additional services when necessary to meet children's special physical and mental need. v. To provide therapeutic intervention and address barriers in parent/child relationships. e. Outcomes of Services: i. Established, maintained or strengthened family relationships. ii. Enhanced well-being of child(ren) and reduced trauma/effects of separation. iii. Increased parenting skills and confidence to provide for children's needs. iv. Measurable increased growth in regard to parenting skills. v. Barriers to parent/child relationship addressed/resolved. f. Target Population: i. Families with children in out -of -home placement who are referred through the Family Courts for parent -child visitation from the Department with visitation needs in Weld County. g. Language: i. English h. Medicaid Eligibility: i. This service is not Medicaid eligible. Service Access and Transportation: i. Contractor will conduct services in the client's home or in the community. ii. Contractor is willing to travel up to 50 miles roundtrip from one of two addresses: 1. 2980 East Harmony Road, Suite 201, Fort Collins, Colorado 80528 2. 6730 Coach Light Court, Timnath, Colorado 80547 5. Individual Therapy a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Eye Movement Desensitization and Reprocessing (EMDR) ii. Cognitive Behavioral Therapy (CBT) iii. Motivational Interviewing iv. Psychoeducation v. Mindfulness vi. Therapeutic Homework b. Anticipated Frequency of Services: i. Two (2) to eight (8) hours per week. c. Anticipated Duration of Services: i. Three (3) to six (6) months, as needed or court ordered. d. Goals of Services: i. To provide diagnostic and/or therapeutic services. ii. To improve the client's mental health, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. iii. Address client welfare specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resiliency. 4 iv. Reprocess maladaptive neuropathways consequences of loss, grief, abuse, and neglect to increase adaptive and resilient responses. v. To decrease or eliminate psychological and somatic suffering due to maladaptive memory storage of sexual trauma. vi. To reprocess maladaptive neuropathways related to sexual trauma. vii. To increasing adaptive response and regulation to triggers related to trauma. e. Outcomes of Services: i. Improved client mental health and impacts of mental health. ii. Client mental health needs addressed related to loss, grief, abuse, neglect, and assist in building resiliency. iii. Client accesses adaptive neuropathways to utilize in regulating emotions and response to life stress and triggers related to experienced trauma. iv. Decreased/Eliminated suffering related to sexual trauma. v. Increased adaptive ability to respond to triggers and life stress. f. Target Population: i. Individuals age three (3) and older experiencing mental health symptoms due to trauma related loss, grief, abuse, neglect, and who require assistance in building resiliency, and are receiving, receiving co-occurring services (including individuals in out -of -home placement who are referred through family courts) from the Department. g. Language: i. English h. Medicaid Eligibility: i. This service is eligible for Medicaid. Service Access and Transportation: i. Contractor will conduct services in the client's home or in the community. ii. Contractor is willing to travel up to 50 miles roundtrip from one of two addresses: 1. 2980 East Harmony Road, Suite 201, Fort Collins, Colorado 80528 2. 6730 Coach Light Court, Timnath, Colorado 80547 6. Family Therapy a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Multisystemic Therapy Theory ii. Eye Movement Desensitization and Reprocessing (EMDR) iii. Cognitive Behavioral Therapy (CBT) iv. Mindfulness v. Psychoeducation vi. Therapeutic Homework b. Anticipated Frequency of Services: i. Two (2) to six (6) hours per week. c. Anticipated Duration of Services: i. Three (3) to six (6) months, as needed or court ordered. d. Goals of Services: i. To provide diagnostic and/or therapeutic services to assist in the development of family services plan. ii. To assess and/or improve family communication, functioning and relationships. 5 iii. To improve the family or dyad's mental health and or relationship, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. iv. Explore family welfare specific needs such as the consequences of loss, grief, abuse, neglect, and assist in building resiliency. v. Reprocess maladaptive neuropathways consequences of loss, grief, abuse and neglect to increase adaptive and resilient responses. e. Outcomes of Services: i. Improved mental health in family members and impacts of mental health. ii. Family member's mental health needs addressed related to loss, grief, abuse, neglect, and assist in building resiliency. iii. Family members can access adaptive neuropathways to utilize in regulating emotions and response to life stress and triggers related to experienced trauma. iv. Improved family communication, functioning and relationships. f. Target Population: i. Family dyads or groups with children zero (0) to 18 years old experiencing mental health symptoms due to trauma related loss, grief, abuse, neglect, and who require assistance in building resiliency, receiving co-occurring services (including individuals in out -of -home placement who are referred through family courts) form the Department. g. Language: i. English h. Medicaid Eligibility: i. This service is eligible for Medicaid. i. Service Access and Transportation: i. Contractor will conduct services in the client's home or in the community. ii. Contractor is willing to travel up to 50 miles roundtrip from one of two addresses: 1. 2980 East Harmony Road, Suite 201, Fort Collins, Colorado 80528 2. 6730 Coach Light Court, Timnath, Colorado 80547 Terms 1. Contractor will respond to the Quality Assurance Team(HS-CWOualitvAssurance(&weld2ov.com within three (3) business days regarding the ability to accept the received referral. 2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team HS- CWQualityAssurance(a weldgov.com. 3. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will 6 place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(a,weldgov.com. 4. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(weldaov.com immediately via email, to discuss service continuation. 5. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 6. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 7. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals will be approved by the caseworker, their supervisor, or the Family Support and Visitation Center. 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. 9. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Quality Assurance Team, and the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and 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 Client Verification Form. 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, if approved by the Department. 10. Contractor will notify the Quality Assurance Team HS-CWQualitvAssurance(aiweldsov.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 7 The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 8 EXHIBIT D 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 specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 2022. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Foster Care/Adoption Support Rate Unit Type Service Name $160.00 Hour Foster Parent Consultation, In-Home/Community $110.00 Hour Foster Parent Consultation, In-Office/Video $180.00 Hour Foster Parent Training, In-Office/Video $200.00 Hour Foster Parent Training, Out -of -Office $65.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $0.50 Mile Mileage - For distances exceeding 50 miles from 2980 E. Harmony Road Suite 201 Fort Collins, Colorado 80528 or 6730 Coach Light Court Timnath, Colorado 80547 $95.00 Hour No Show Life Skills Rate Unit Type Service Name $65.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Making, Professional Staffing $0.50 Mile Mileage - For distances exceeding 50 miles from 2980 E. Harmony Road Suite 201 Fort Collins, Colorado 80528 or 6730 Coach Light Court Timnath, Colorado 80547 $95.00 Each No Show $95.00 Hour Supervised Visitation, In-Home/Community $65.00 Hour Supervised Visitation, In-OfficeNideo $135.00 Hour Therapeutic Visitation, In-Home/Community $90.00 Hour Therapeutic Visitation, In-OfficeNideo Mental Health Services Rate Unit Type Service Name $180.00 Hour Family Therapy, In-Home/Community $120.00 Hour Family Therapy, In-OfficeNideo $65.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Making, Professional Staffing $180.00 Hour Individual Therapy, In-Home/Community $120.00 Hour Individual Therapy, In-OfficeNideo $0.50 Mile Mileage - For distances exceeding 50 miles from 2980 E. Harmony Road Suite 201 Fort Collins, Colorado 80528 or 6730 Coach Light Court Timnath, Colorado 80547 $95.00 Each No Show Therapeutic Kinship Support Rate Unit Type Service Name $65.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Making, Professional Staffing $160.00 Hour Kinship Services, In-Home/Community $110.00 Hour Kinship Services, In-OfficeNideo $0.50 Mile Mileage - For distances exceeding 50 miles from 2980 E. Harmony Road Suite 201 Fort Collins, Colorado 80528 or 6730 Coach Light Court Timnath, Colorado 80547 $95.00 Each No Show 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report 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 and Exhibit A. 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 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. New Contract Request Entity Name* Entity ID' SOVEREIGNTY COUNSELING SERVICES CdO0O42283 PLLC Contract Name* SOVEREIGNTY COUNSELING SERVICES PLLC (CHILD PROTECTION AGREEMENT) Contract Status CTB REVIEW Contract Description * BID# 82100O42. TERM: 6,' 1 '21-5i 31 '22. ❑ New Entity? Contract ID 4785 Contract Lead* APEGG Contract Lead Email apeggOweldgov. corn; cobbx xlk@tweldgov.com Contract Description 2 MEMO WAS PRESENTED TO THE BOCC BY PURCHASING ON 4,7/°2021 TYLER ID. 2O21-0307. Contract Type* AGREEMENT Amount $0.00 Renewable* NO Automatic Renewal Grant Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.co m Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY Ai I ORNEY EMAIL County Attorney Email CM- COUNTYATTORN EY@WELOG OV.C:OM Requested BOCC Agenda Date* 05:`26/2021 Will a work session wi NO Parent Contract ID 20210307 Requires Board Approval YES Department Project # Due Date 05!22/2021 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 It] Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On8ase Contract Dates Effective Date Review Date* 04:01 =2022 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name ping Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 05/2012021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 05:26,2021 Originator APEGG Committed Delivery Date Expiration Date* 05,3112022 Contact Type Contact Phone 2 Finance Approver CONSENT Purchasing Approved Date 05,20,'2021 Legal Counsel CONSENT finance Approved Date Legal Counsel Approved Date 0512012021 052012021 Tyler Ref # AG 052621 Hello