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Home My WebLink About20211467.tiffCCohtvuC;-1 D # (09 Lo7 canes►+ do, V71/2,3 PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: May 16, 2023 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment #2 with Northern Colorado Counseling & Assessment, LLC 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 Agreement Amendment #2 with Northern Colorado Counseling & Assessment, LLC. The Department has an Agreement with Northern Colorado Counseling & Assessment, LLC for Mental Health and Sexual Abuse Treatment Services. This Agreement is known to the Board as Tyler ID# 2021-1467. The agreement is now being amended to renew for a third and final year, for the period June 1, 2023 through May 31, 2024, and to make changes to the Scope of Services and Rate Schedule as noted below. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Scope of Services Changes: • Updates to the terms as requested by the Department. Rate Schedule Changes: • Updates to the terms as requested by the Department. • Updates to the rates as requested by the Contractor. P1O,18111 :NIGH Mental Health Services 1,,I, $765.00 tnit 11it' i Episode ',CI, ICI. v.,II�C Mental Health Evaluation (Only via ln-office7Video) $350.00 Hour Psychological Evaluation (Only via in-office/Video) $150.00 Hour Mental Health Services: Consultation (Only via In- office/Video) $120.00 Hour Mental Health Services: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $200.00 Each Mental Health Services: No Show (Max of 2 no shows or 2 hours/month/client) $0.56 Mile Mental Health Services: Mileage Sexual Abuse Treatment $1,000.00 Episode Psychosexual Evaluation: Sex Offense Specific Pass -Around Memorandum; May 16, 2023 — CM�0C7� i� Page 1 ZOZ1-14101 i*O0R3 PRIVILEGED AND CONFIDENTIAL Sexual Abuse Treatment $200.00 Each Psychosexual Evaluation: No Show (Max of 2 no shows or 2 hours per evaluation) $120.00 Hour Sexual Abuse Treatment Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $120.00 Hour Boundaries Course (Only via In-office/Video; occasional travel to Weld County Jail - 2110 O Street, Greeley, CO) $120.00 Each Boundaries Course: No Show (Max of 2 no shows or 2 hours/month/client) $150.00 Hour Informed Supervision Training $150.00 Each Informed Supervision Training: No Show (Max of 2 no shows or 2 hours/month/client) $0.56 Mile Sexual Abuse Treatment: Mileage I do not recommend a Work Session. I recommend approval of this Agreement Amendment #2 and authorize the Chair to sign. Approve Schedule Recommendation Work Session Other/Comments: Perry L. Buck, Pro -Tern Mike Freeman, Chair Scott K. James Kevin D. Ross Lori Saine rAE- Pass-Around Memorandum; May 16, 2023 — CMS ID 6967 Page 2 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND NORTHERN COLORADO COUNSELING AND ASSESSMENT, LLC 7VId This Agreement Amendment, made and entered into day of NA l , 2023 by and between the Board of Weld County Commissioners, on behalf of the Weld County Deparhnt of Human Services, hereinafter referred to as the "Department", and Northern Colorado Counseling and Assessment, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services and Sexual Abuse Treatment (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1467, approved on June 2, 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 4, 2022 to extend the term date through May 31, 2023. • The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2021-1467. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement as of June 1, 2023: 1. Term: This agreement is being renewed fora third, and final year, for the period of June 1, 2023 through May 31, 2024. 2. Exhibit C, Scope of Services, is hereby amended as attached. 3. Exhibit D, Rate Schedule, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. O2oa-/_ 141,1 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: B ',1..CG��1J Cam• �K BOARD OF COUNTY COMMISSIONERS erk to the Board WELD COUNTY, COLORADO jjk/i., 4, 9 eputy Cler to the Bo./�. \� 4 l si Mike Freeman, Chair MAY 2 2 2323 NTRACTOR: orthern Colorado Counseling & Assessment, LLC 4689 West 20th Street, Suite E Greeley, Colorado 80631 Christina Rascon Gentry By: Christina Rascon Gentry (May 8, 202313:05 MDT Christina Rascon Gentry, Psychologist Date: May 8, 2023 ozpoz-/- /4-1,7 EXHIBIT C SCOPE OF SERVICES Contractor will provide Mental Health Services and Sexual Abuse Treatment, as referred by the Department. Mental Health Services 1. Mental Health Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Clinical interview. ii. Limited testing including mini mental status, brief personality inventory, and a symptom inventory. b. Anticipated Frequency of Services: i. One (1) appointment for three (3) to four (4) hours. c. Anticipated Duration of Services: i. One (1) time. d. Goals of Services: i. To gain a greater understanding of the client's mental health functioning including: 1. Presence of any mental health symptoms/disorders. 2. How the symptoms are impacting the client's functioning. 3. How to best address the client's mental health concerns. e. Outcomes of Services: i. A report that addresses any mental health symptoms the client may be experiencing. ii. Recommendations for an appropriate treatment plan. iii. Identification of other services such as mentoring and family therapy that the client may benefit from. f. Target Population: i. Ages 13 and older. ii. Male and female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In Contractor's office located at 4689 West 20th Street, Suite E, Greeley, Colorado 80631. ii. Virtually. 2. Psychological Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Clinical interview. ii. Multiple questionnaires and inventories related to personality, trauma, and substance use. iii. Projective assessments including the Thematic Apperception Test and Rorschach Inkblot Test. 1 iv. IQ/Cognitive functioning testing. v. Memory testing. vi. Malingering/effort testing. vii. Coordination with other professionals such as the client's therapist, probation officer, or significant other to obtain collateral information regarding the client's functioning. viii. Each assessment is designed to meet the client's specific needs and ensure the referral question is answered. b. Anticipated Frequency of Services: i. One (1) four (4) to six (6) hour testing session per week. Testing time will vary depending on the case. c. Anticipated Duration of Services: i. Typically, two (2) to three (3) testing sessions. d. Goals of Services: i. Provide a wholistic picture of the client including their mental health functioning, personality structure and how they interpret/perceive themselves, the world, and others. ii. Provide information regarding the client's cognitive functioning and whether or not they are able to function and/or meet the expectations set for them. iii. If memory is a concern, testing could determine if the client has true deficits in memory. Furthermore, a psychological evaluation could include malingering testing to determine if the client is feigning or exaggerating symptoms. e. Outcomes of Services: i. A report that identifies: 1. The client's current level of functioning including mental health symptoms or any diagnosis that may be present. 2. A proposed treatment plan. 3. Identification of other services the client may benefit from that would help set them up for success. f. Target Population: i. Ages 13 and older. ii. Male and female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In Contractor's office located at 4689 West 20. Street, Suite E, Greeley, Colorado 80631. ii. Virtually. 3. Consultation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Modalities, curriculum, and tools will be determined based upon the needs of the referral source. ii. Contractor will utilize her professional expertise in the Sex Offender Management Board (SOMB) field and knowledge as it relates to clinical psychology. b. Anticipated Frequency of Services: 2 i. As needed. c. Anticipated Duration of Services: i. As needed. d. Goals of Services: i. Provide Department employees guidance in how to best accommodate a client or handle the current case. e. Outcomes of Services: i. Department employees would gain guidance on how to best accommodate a client or handle the current case. f. Target Population: i. Department employees. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In Contractor's office located at 4689 West 20. Street, Suite E, Greeley, Colorado 80631. ii. Virtually. Sexual Abuse Treatment 1. Sex Offense Specific/Psychosexual Evaluations Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Sex Offense Management Board (SOMB) Standards and Guidelines. ii. Clinical interview. iii. Risk assessments: 1. Sex Offender Treatment Intervention and Progress Scale (SOTIPS). 2. Vermont Assessment of Sex Offender Risk -II (VASOR-II). 3. Juvenile Sex Offender Assessment Protocol -II (JSOAP-II). 4. Child Pornography Offender Risk Tool (CPORT). 5. As well as psychological and sexual functioning assessments. b. Anticipated Frequency of Services: i. One (1) four (4) to five (5) hour appointment. c. Anticipated Duration of Services: i. One (1) time evaluation. d. Goals of Services: i. Determine client's risk level. ii. Determine client's appropriate level of supervision. iii. Inform client's treatment planning. iv. Identify any other services that help set the client up for success. e. Outcomes of Services: i. Identify client's risk level. ii. Identify an appropriate level of supervision/containment. 3 iii. Propose a treatment plan. f. Target Population: i. Ages 13 and older. ii. Male and female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In Contractor's office located at 4689 West 20. Street, Suite E, Greeley, Colorado 80631. ii. Virtually. 2. Boundaries Course a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Sex Offense Treatment topics including appropriate boundaries, healthy relationships and healthy sexuality, consent, communication, emotion management, decision making and problem -solving skills, impulse control, empathy, cognitive distortions and reframing distorted thinking, and self-esteem. b. Anticipated Frequency of Services: i. Individual: One (1) time per week for 45-50 minutes. ii. Group: One (1) time per week for one (1) hour. c. Anticipated Duration of Services: i. Twelve (12) weeks. d. Goals of Services: i. Develop a thorough understanding of healthy and appropriate boundaries in any and all relationships such as romantic relationships, familial relationships, and professional relationships. ii. While learning about boundaries, the client will learn basic life skills such as communication, thinking errors, and accountability that will help facilitate the process of identifying, respecting, and enforcing appropriate boundaries. iii. Client will demonstrate internalization of the Boundaries curriculum through daily life application. e. Outcomes of Services: i. Client will show an understanding of the Boundaries curriculum and demonstrate they have internalized treatment topics and can apply such knowledge to novel situations. ii. Client will show how they will apply the skills they have learned in treatment. Target Population: i. Ages 13 and older. ii. Male and female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. 4 i. Service Access and Transportation: i. In Contractor's office located at 4689 West 20. Street, Suite E, Greeley, Colorado 80631. ii. Virtually. 3. Informed Supervision Training a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Sexual Offence Management Board (SOMB) standards and guidelines. ii. Family safety contract. iii. Chaperone responsibility statement. b. Anticipated Frequency of Services: i. One (1) to two (2) hours. c. Anticipated Duration of Services: i. One (1) training appointment. d. Goals of Services: i. To provide the client with information regarding the following topics: SOMB History and Principles, line of sight and supervision and child contact, safety planning, risk factors and triggers, underlying factors of sexual offending, responsibility and victim impact, the behavior chain, empathy, grooming, consent, rational for informed supervision, how to encourage and model healthy behaviors, and responsibilities of an informed supervisor. ii. Client will also learn the different types of treatment that may be recommended and potential expectations of treatment/supervision. e. Outcomes of Services: i. For the client to demonstrate an understanding of the topics listed under "goals of services" as well as an expressed willingness to have open and honest communication with the Multidisciplinary Team (MDT)/Community Supervision Team (CST). The client shall express their willingness to be an informed supervisor and be willing to adhere to the rules/restrictions. The client should be willing to not only support the identified patient but also be able to hold them accountable and/or intervene if needed. f. Target Population: i. Ages 18 and older. ii. Male or female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. In Contractor's office located at 4689 West 20. Street, Suite E, Greeley, Colorado 80631. ii. Virtually. 5 Terms 1. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. 2. Contractor agrees to receive referrals for services through e-mail and will provide an identified e-mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. 3. Contractor will respond to the Mental Health and Support Services Team CWServiceReferral(a,weldgov.com within three (3) business days regarding the ability to accept the received referral. 4. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Mental Health and Support Services Team (HS - C W ServiceReferral(a�weldeov.com). 5. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Mental Health and Support Services Team(HS-CWServiceReferral(a,weldeov.com). No other Department staff or other party to the case may authorize services or modifications to services. 6. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no-shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 -hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharge the client from services. Contractor must inform the caseworker and the Mental Health and Support Services Team (HS- CWServiceReferral(al/weldgov.com) within three (3) days of when the client is placed on a behavioral plan or discharged 7. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Mental Health and Support Services Team(HS-CWServiceReferral(a,weldeov.com) immediately via email, to discuss service continuation. 8. Contractor will identify, in detail, areas of continued concern and make recommendations to the caseworker in a monthly report regarding continuation of services and/or the need for additional services. 6 9. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 10. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported to the caseworker and the Mental Health and Support Services Team (HS-CWServiceReferral(u�weldgov.com) immediately AND on the required monthly report. 11. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Mental Health and Support Services Team. Any changes to visitation referrals will be approved by a new referral signed by the Child Welfare Supervisor. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 12. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Stuffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Mental Health and Support Services Team, and the facilitator documents in the meeting notes the timeframe that the provider attended and when participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the meeting notes. Stuffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone or virtually, if approved by the Department. 13. On a monthly basis, the Contractor will notify the Mental Health and Support Services Team (HS- CWServiceReferral/d/weldgov.com) of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 14. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 9 of this Exhibit. 7 15. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 16. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 17. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be personally served. 18. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department, and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients to sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 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(s) specified below in Paragraph 2, Fees for Services. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. For services funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check, deposit slip or bank letter. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. For services not funded through Core Services; Contractor agrees to accept payment through County Warrant when funding source does not allow for direct deposit. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Program Area Mental,l ealth Services Rate $765.00 Unit Ty Pe Episode Seryice Name Mental Health Evaluation (Only via Iu-o "ice/ der). $350.00 Hour Psychological Evaluation (Only via In-office/Video) $150.04 ; Hour Mental Health Services: Consultation (Only via ln- officeNideo) $120.00 Hour Mental Health Services: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $200.00 Each Mental Health Services: No Show (Max of 2 no shows or 2 hours/month/client) $0.56 Mile Mental Health Services: Mileage* Sexxtat Abuse Treatment $1,000.00 Episode Psychosexual Evaluation: Sex Offense Specific $200.00 Each Psychosexual Evaluation: No Show (Max of 2 no shows or 2 hours per evaluation) $120.00 flour Sexual. Abuse Treatment: Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $120.00 Hour Boundaries Course (Only via In-office/Video; occasional travel to Weld County Jail - 2110 O Street, Greeley, CO) $'124.04 Each Boundaries Course: No Show (Max of 2 na shows or 2 (curs/trionth/client) $150.00 Hour Informed Supervision Training $150.00 Each Informed Supervision Trai g: No Show. (Max of 2 no lxws: cat 2 hours/mantlr/client) $0.56 Mile Sexual Abuse Treatment: Mileage* * For distances exceeding 20 miles from 4689 W. 20th Street, Greeley, CO. 3. Request for Reimbursement and Supporting Documentation Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7. day of the month following the month of service, but no later than 45 days from the date of service for each client receiving ongoing services. Contractor shall prepare and submit monthly a Request for Reimbursement and monthly report including other supporting documentation, if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 of this Agreement. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Time(s) of service (i.e. 2-4pm) b. Location of where the service took place (i.e. clinician's office, client's home, in the community.) c. Clinician/therapist name d. What interventions were used, recommendations and/or goals discussed, progressions towards goals, and client engagement. e. For mileage reimbursement, if applicable, the mileage accumulated minus roundtrip mileage that is included in the rate, starting location, and ending location. f. Any and all safety concerns. When submitting a Request for Reimbursement for a one-time service, the contractor shall submit the first and last page of the evaluation/report to confirm proof of services rendered. The full evaluation/report should be submitted by the contractor to the caseworker. For Monitored Sobriety services, proof of services rendered shall be the test result. Requests for Reimbursement and/or supporting documentation received after the 7. day of the month may delay payment. Requests for Reimbursement and/or supporting documentation received after 45 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 45 -day deadline may result in termination of the Agreement. 4. Payment The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: The service being provided by the contractor is not a Medicaid eligible service; a. The service is not deemed medically necessary; b. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; c. A Medicaid provider is not available to provide the needed service; d. Medicaid is exhausted for the needed service; or e. Medicaid denied service. f. The client is not eligible for Medicaid. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture ofpeimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: a. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. b. Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 6. Financial Management At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMB Circular A-133. SIGNATURE REQUESTED: Weld/NC Counseling & A Amend #2 - 2023-24 Final Audit Report 2023-05-08 Created: 2023-04-21 By: Lesley Cobb (cobbro4k@co.weld.co.us) Status: Signed Transaction ID: CBJCHBCAABAAaKyJXW_vjrpzFrKbDeAnyMF48HBSX3ZT "SIGNATURE REQUESTED: Weld/NC Counseling & A Amend #2 - 2023-24" History t Document created by Lesley Cobb (cobbxxlk@co.weld.co.us) 2023-04-21 - 6:03:04 PM GMT- IP address: 204.133.39.9 P. Document emailed to dr.rascon@nococounseling.co for signature 2023-04-21 - 6:03:52 PM GMT t Email viewed by dr.rascon@nococounseling.co 2023-04-21 - 6:53:06 PM GMT- IP address: 104.28.48.213 t Email viewed by dr.rascon@nococounseling.co 2023-04-24 - 8:27:37 PM GMT- IP address: 104.28.48.218 t Email viewed by dr.rascon@nococounseling.co 2023-04-28 - 4:09:54 AM GMT- IP address: 104.28.48.214 ,n Email viewed by dr.rascon@nococounseling.co 2023-05-02 - 4:41:39 AM GMT- IP address: 172.225.198.58 t Email viewed by dr.rascon@nococounseling.co 2023-05-03 - 7:13:22 PM GMT- IP address: 104.28.48.217 t Email viewed by dr.rascon@nococounseling.co 2023-05-06 - 7:38:45 PM GMT- IP address: 104.28.48.215 Gj® Signerdr.rascon@nococounseling.co entered name at signing as Christina Rascon Gentry 2023-05-08 - 7:05:23 PM GMT- IP address: 98.38.11.143 d© Document e -signed by Christina Rascon Gentry (dr.rascon@nococounseling.co) Signature Date: 2023-05-08 - 7:05:25 PM GMT - Time Source: server- IP address: 98.38.11.143 Powered by Adobe Acrobat Sign {� Agreement completed. 2023-05-08 - 7:05:25 PM GMT Contract Form Contract Request Entity Information Entity Name:* Entity ID* NORTHERN COLORADO COUNSELING 000042695 & ASSESSMENT LLC Contract Name * NORTHERN COLORADO COUNSELING & ASSESSMENT LLC. (AGREEMENT AMENDMENT PY 2022-231 Contract Status CTB REVIEW Contract ID 6967 Contract Lead* COBBXXLK ❑ New Entity? Parent Contract ID 20211467 Requires Board Approval YES Contract Lead Email Department Project cabb: oIk co.weld.co.us Contract Description * BIDA 62100042. MINOR SCOPE, RATE AND TERM CHANGES. TERM 6. 1 r23 5131.'24. Contract Description 2 PA ROUTING THROUGH NORMAL APPROVAL PROCESS. ETA TO CTB 5 18 23. Contract Type* AMENDMENT Amount* 50.00 Renewable* ND Automatic Renewal Grant IGA If this is a renewal enter Department HUMAN SERVICES Department Email CM- HumanServicessuweldgov.co R1 Department Head Email CM-HumanServices- DeptHeadC,weldgov.com County Attorney GENERAL COUNTS ATTORNEY EMAIL County Attorney Email CM - CDU NTYATTORN EYWW ELDG OV.COM Contract ID If this is part of a MSA enter MSA Contract ID Requested BOCC Agenda Date 05 24; 2023 Due Date 0520?2023 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be induded? 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 Review Date * 03129:2024 Renewal Date Termination Notice Period Contact Information Contac Contact Name Committed Delivery Date Contact Type Contact Email Expiration Date 05;31;2024 Contact Phone I Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date CONSENT Approval Process Department H JAMIE ULf'.ICH DH Approved Date 05,10 2023 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 05:'22;2023 Originator C000XXLK 05 10 2023 finance Approver CONSENT Legal Counsel CONSENT finance Approved Date Legal Counsel Approved Date 05=10 2023 05,'10,`2023 Tyler Ref # AG 052223 PRIVILEGED AND CONFIDENTIAL MEMORANDUM COnch7a,c31.1*519(4 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-Tem Scott K. James, Chair Steve Moreno Lori Saine Approve Schedule Recommendation Work Session 6i-trAal Other/Comments: Pass -Around Memorandum; March 29, 2022 - CMS ID — Various Page 1 Cone 05/ 04/ZZ c&gual4.O4-s--D) --/471/02D.A.,2 ZUZI -14O t-}l201YA3 PRIVILEGED AND CONFIDENTIAL CMS Name Behavior Services of the Rockies Bid # B2100042 Bid Year 2021-22 Ty er 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 B2100042 2021-22 2021-1439 Specialty Counseling & Consulting B2100042 2021-22 2021-1466 The Hope Initiative B2100042 2021-22 2021-1582 Tindall and Associates B2100042 2021-22 2021-1606 VitatCare 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@weldgov,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 Executive Assistant & Office Manager, Board of Weld County Commissioners 1150 0 Street, P.O. Box 758, Greeley, Colorado 80632 :: 970.336-7204 :: kfordweldgov.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 NORTHERN COLORADO COUNSELING AND ASSESSMENT, LLC This Agreement Amendment, made and entered into 4 day of 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human S ices, hereinafter referred to as the "Department", and Northern Colorado Counseling and Assessment, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services and Sexual Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1467, approved on June 2, 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 enc 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. ATTEST: BY: COUNTY: BOARD OF COUNTY COMMISSIONERS WEL►COUNTY, COLORADO Deputy Cle to the: rd �j �� c' r K. James, Chair MAY 0 4 2022 Northern Colorado Counseling and Assessment, LLC 4689 West 20th Street, Suite E Greeley, Colorado 80631 Nom C iftr�ra Sarum G2vey By:Nora Christina Rascon Gentry (Apr 25, 2022 15:47 MDT) Dr. Nora Christina Rascon Apr 25, Date: Contract Form New Contract Request Entity Information ❑ New Entity? Entity Name* Entity ID* NORTHERN COLORADO COUNSELING 8O0042695 & ASSESSMENT LLC Contract Name* NORTHERN COLORADO COUNSELING & ASSESSMENT LLC (AGREEMENT AMENDMENT PY 2022-23) Contract Status CTB REVIEW Contract Description* BID# B2100042. TERM 611 Contract Description 2 CONSENT: PA WAS SENT TO Contract Type* AMENDMENT Amount * $0.00 Renewable* NO Automatic Renewal Grant IGA 22-5/31/23. CTB ON: 3/30:2022. Department HUMAN SERVICES Department Email CM- HumanServicesOweldgay.co m Department Head Email CM-HumanServices- DeptHeadWeldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WELDG OV.COM If this is a renewal enter previous Contract ID Contract ID 5794 Contract Lead* APEGG Contract Lead Email apegg@weldgov.com;cobbx xlk@iweldgov.com Requested RD!CC Agenda Date* 05 25;2022 Parent Contract ID 20211467 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? If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 0403; 2023 Renewal Date Termination Notice Period ormation Contact info Contact Name Po Purchasing Approver Approval Department Head JAMIE ULRICH DH Approved Date 04/28,2022 Final Approval BOCC Approved BOCC Signed Date &)CC Agenda Date 05,04,2022 Originator APEGG Contact Type Committed Delivery Date Contact Email finance Approver CHERYL PA I I ELLI Expiration Date* 05/31/2023 Contact Phone 2 Purchasing Approved Date Finance Approved Date 04/28/2022 Tyler Ref 050422 Legal Counsel CAITLIN PERRY Legal Counsel Approved Date 04,'28,= 2022 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND NORTHERN COLORADO COUNSELING AND ASSESSMENT, LLC 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 epartment of Human Services, hereinafter referred to as the "Department' and Northern Colorado Counseling a d Assessment, LLC, hereinafter referred to as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, 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 Mental Health Services and Sexual Abuse Treatment. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 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(aweldgov.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. Contractor agrees that original complete Client Verification Forms are to be submitted with the le -A -1-0---/c& ?L 2( `p ,az -ou / � � a,/ 2021-1467 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: For Contractor: Heather Walker, Child Welfare Director Dr. Nora Christina Rascon 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich, Director P.O. Box A Greeley, Colorado 80632 (970) 400-6510 18. Litigation For Contractor: Dr. Nora Christina Rascon 4689 West 20th Street, Suite E Greeley, Colorado 80631 (720) 588-0565 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. .S424-18-201 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: Al"I'hST: d,,daffAj W [o;ti BOARD OF COUNTY COMMISSIONERS Weld C . . ty Clerk to the Board WELD COUNTY, COLORADO By Deputy Clerk to 13 Scott K. James, Pro-Tem JUN 0 2 2021 CONTRACTOR: Northern Colorado Counseling and Assessment, LLC 4689 West 20th Street, Suite E Greeley, Colorado 80631 (720) 588-0565 Nato Chfirt%?1a RIG011 By: Nora Christina Rascon (May 19, 2021 11:23 MDT) Date: Dr. Nora Christina Rascon May 19, 2021 02_0,1- /4/6 7 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) ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES — PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION Agency Name: Northern Colorado Counseling & Asssessment D Provider Contact Full Name: Nora "Christina" Rascon Primary Phone Number (10 -digit): 720-588-0565 Ext : dr.rascon@nococounseling.co Primary Contact Email: Trails Provider ID (if known): Title: Dr. Agency Location Address (Street, city, state, zip): Agency Mailing Address (Street, city, state, zip): Fax Number (10 -digit): Web Address: 4689 W 20th St, Suite E, Greeley, CO same as above Agency Type (pick one): l i Public Company n Private Non -Profit Private for Profit Referral Contact Name: Send Referrals for Service to: Christina Rascon Title: Dr. 720-588-0565 dr.rascon@nococounseling.co Referral Phone Number (10 -digit): Ext.: Email: Billing Contact Billing Contact Name: Christina Rascon Title: Dr. 720-588-0565 dr.rascon@nococounseling.co Billing Phone Number (10 -digit): Ext.: Email: CERTIFICATION II certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the j specifications it has so indicated in this bid form. I further affirm intention to enter into an agreement with Weld County, on ibehalf of the Weld County Department of Human Services, and comply with all requirements of the contract, if awarded. The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to accept 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: Authorized Rep. Email: Nora Christina Rascon Title: Dr. dr.rascon@nococounseling.co Phone (10 -digit): 7205880565 Ext.: Authorized Rep. Address (Street, city, state, zip): Signature of Authorized Rep.: 4689 W 20th St, Suite E, Greeley, CO Date: 05/19/2021 REV. NOVEMBER 2020 ATTACHENT C ® PROPOSAL Please type your (1 nswers in the b xesb low r ch ck the appropriate b B ri d e is Legal Na m e: Program Ar SECTION 1— Provider an .4 P r gram f €4 ation N 4 rtherrt Colorado Counseling & Assessment, LLC Mental Health Scrvices umbr Pmgrnm Areas we listed in column 1 of the table located in item XI of the Request Your may c for Proposal starting on page 11 11 f services offered on this Attachment C (max 5): mplete another Atta chment C if y u have more than 5 3 rift SECTION t - Service Name(s) and Infc;rmatiLr e service as a monthly pac k a e, pleas -+ offer different levels. All state a specofa& minimum number of direct service h anti* •�urso p es rn ust serve: `? Name: ental Healtri Evaluatin 2.1a It zdalities, curriculum, tools wed in delivery of service (D NOT list company history; D use ullet points): mental health evaluation inckides the use of a clinical interview and limited testing t personality invent .. ry, and a sytptfsm inventory. 4 include a mini mental status, brie 2o1h Anticipated frequency of direct service time with the client/family per week not including pr fessi:}nal staffing time, a rninistrative time, verhead, or travel time (i.e. 4 hours/week). If the service has levels, be spcific fr each level: One three to four-hour appointment 2.1c Anticipated duration of service (Lee 3=4 months): One thr ya e urmh ur appointment 2m1d Three (3), or m re, specific goa s f the service (DO use bullet points): To gain a greater understanding of the client's mental health functioning including the presence of any mental health symptoms/disord rs, how the nympttms are impacting the client's functioning, and hsw tbest address their mental health ctncernsa 2.1e Three (3),orm specific outc mes of ser is The outcome of the evaluation would be a report that addresses any . rental health symptoms the client may be experiencing, rec rnmendatims fcrr an appropriate treatment plan, as well as identFying other services (e.g. mentor, family therapy, etc.) the client oay benefit from. 2.1f f Target p pulati:>n of the s rvice, including age and gender: Males and females (ages 10+) 2.1g Languages service is available i■ (please list proficiency and if interpreter services are available): English and Spanish _fluent cam sp-ak, read, and write in b• -th languages. 2.1h Medicaid eligibility e list whether the service is eligible f Service ice #2 Name: r Medicaid in whole or in part: Psychological Evaluation 2.2a Mcwdalities, curriculum, tools used in delivery f service (DO NOT list company history; DO use bullet p ints): A psychological evaluatitn is a omprehensive evaluation that carp include but is not limited ta clinical intervie multiple questionnaires/inventori-,s (related to personality, trauma, substance use, etc.), projective assessments (Thematic Appercept to Test *r Rorschach Inkblot Test), 1: c::;gnitive functioning testing, memory testing, and malingering/effort testing. Each assessment batten is designed to meet the client's specific : Y -ds and ensure the referral question is answered. In some cases, this may ;;Is include crdination with other professi finals such as the client's therapist, probation *ff cer, significant other to obtain collater;I inf*rmati*n regarding the client's functioning. 202b Anticipated frequency f direct rvice time with the client/family per we k, nett including pr fessional staffing time, i.� ,es administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: One 4 -6 -hour testing sessin pet week (testing time will vary depending on the c • mplexity Lsf the assessment battery and testing being co pitted) 2.2c Anticipated duration ®f service 0.e. 3-4 months): Typically, two testing sessins 202d Three (3), r more, specific g4all of the service (DO use bullet p ;I) * ints): The g al is to pr vid a wh*listic picture ff the client including their mental health functioning, personality structure, and how they interpret/perceive themselves, the world, and others. A psychgical evaluation can also; provide infti•:rmatSn regarding the client's cognitive functifling and whether ti r not they are able to function and/or meet the expectations set L REV. N 2020 1 ATTACHMENT C - PROPOSAL for them. If memory is a concern, testing could determine if the client has true deficits in memory. Furthermore, a psychological evaluation could include malingering testing to determine if the client is feigning or exaggerating symptoms. 2.2e Three (3), or more, specific outcomes of service: The outcome of the testing sessions and clinical interview would be an organized, easy to read comprehensive report that identifies the client's current level of functioning including mental health symptoms or any diagnosis that may be present, a proposed treatment plan, and identifying other services the client may benefit from that would help set them up for success. 2.2f Target population of the service: Males and females (ages 10+) 2.2g Languages service is available in (please list proficiency and if interpreter services are available): English and Spanish — fluent can speak, read, and write in both languages. 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: NO Service #3 Name: Consultation 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): This will be determined based upon the needs of the referral source. This clinician will utilize her expertise in the SOMB field and/or knowledge as it relates to clinical psychology. 2.3b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: As needed 2.3c Anticipated duration of service (i.e. 3-4 months): As needed 2.3d Three (3), or more, specific goals of the service (DO use bullet points): 2.3e The goal of the consultation would be to provide the referral source and/or other professionals guidance in how to best accommodate a client or handle the current case. Three (3), or more, specific outcomes of service: As noted above, the outcome would be to provide guidance, knowledge, and understanding to the referral source regarding my area of expertise. 2.3f Target population of the service: Professionals 2.3g Languages service is available in (please list proficiency and if interpreter services are available): English and Spanish — fluent can speak, read, and write in both languages. 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: No Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3), or more, specific goals of the service (DO use bullet points): 2.4e Three (3), or more, specific outcomes of service: 2.4f Target population of the service: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #5 Name: 2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): REV. NOV 2020 2 ATTACHMENT C - PROPOSAL 2.5b Anticipated frequency of direct service time with the client/family per week, not including professi;• nal staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c nticipat-d duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part Section 3 — Service Access and Transportation 3.1 Will you charge Weld County for transporting clients or mileage? Check one: 3.2 Will you conduct services in a client's home or in the community? Check one: 3.3 Will you transport clients to and/or from services? Check one: ■ YES 3.4 How many miles are you willing to travel round trip? List a specific number of miles. 3.5 When you calculate mileage, what is your starting point address? YES NO YES NO 120 H Miles 4689 W 20th St, Greeley, CO SECTION 4 SERVICE RATES All rates need to include administrative work (i.e. scheduling or report writing) and oa er eado Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except f , r those listed above. ® For hourly rates complete section(s) 4.1-4.5. p S • For monthly rates complet-, section 4.6. ® For Home study prividers complete section 4.7. For monitored sobriety testing providers complete section 4.8. 4.1 Hourly Service #1 Name: 4.1a Mental Health Evaluation In-Office/Video: 4.1b In -Office with Transportation: In -Home or Community: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate: $ Amount 600 600 120 200 . 56 Unit Type per Evaluation per Hour per Hour per Hour per No Show per Mile No. • f miles included in rate: No. of miles included in rate: 20 This is paid after the miles listed abov miles miles 4.2 Hourly Service #2 Name: Psychological Evaluation 4.2a In-Office/Video: 4.2b In -Office with Transp: :rtation: 4.2c In -Home or Community: $ Amount 350 ▪ IM 350 Unit Type per Hour per Hour per Hour No. of miles included in rate: No. of miles included in rate: 20 miles miles REV. NOV 2020 3 ATTACHMENT C o PROPOSAL 4.2d FTM, TDM, Prof. Staffing: 120 per Hour 4.2e No show: 200 per No Sh w 4.2f Mileage rate: .56 per Mil- This is paid after the miles listed above. 403 Hourly Servicf,: 43 Name: Consultation $Am sunt Unit Type 4.3a ln-Office/Video: 150 per Hour 403b In -Office with Transportation: per Hour No. of miles included in rate: miles 4.3c In -Home or Community: per Hour No. of miles included in rate: miles 4.3d FTM, TDM, Prof. Staffing: per Hour 4.33e No she, w: per No Show 4.3f Mileage rate: per Mile This is paid aft -r the milts listed above. 1 4.4 H urly Service #4 Name: $ Ams unt Unit Type 4.4a In-Office/Video: per H •cur 4.4b In -Office with Transportation: per Hour ``:go. of miles included in rate: mils-_ s In -H • me or C• mmunity: per Hour No. of miles included in rate: miles 4.4c FTM, TDM, Prof. Staffing: per Hour 4.4d No show: per N Show 4.4e Mile?ge rate: per Mile This is paid after the miles listed above. 4.5 Hourly Service #5 Name: $ Amount Unit Type 4.5a 0n ffice/Vide:: per H•;ur 4.sb In -Office with Transp•;rtati in: per Hour No. of miles included in rate: miles 4.5c In -Nome or Cr mmunity: per Hour No. of miles included in rate: miles 4.5d FT I 1, TCMM, Prof. Staffing: per H. ur 4.5e E%ks show: per No Show 4.5f Mileage rate: per Mile This is paid after the miles listed above. 4.6 M:•:nthly Service Rates (each level must be listed): Service Name \\ ith Level Rate per Month No. of Direct Service Hours: 4.62 406b 4.6c 4.6d 4.6e ,4.6f 4.6g 4.6h 4.6i 4.6j 4.7 Hitme Study Pr.:viders ® List your rates in the box below. 4.8 Monitored Sobrkity Pr !• viders - List yJ ur rates in the box bellow. Provider special notes: In Section 3, I checked the box indicating I will provide services in the community, which includes group homes and/or detention facilities. However, l do not provide IN -HOME services. REV. NOV 2020 4 ATTACH 1101 E E;: T C Please type your answers in the boxes below or check the appropriate box. Bidder's Le Pr tram /}arc., gram fit rea: SECTION 1- Provld - r x nd P ram Ar a kyf radon Northern Colorado Counseling & Assessment, LLC Sexual Abuse Treatment rete n are listed in column 1 of the table located in Item XI of the Request for Prop -• sal starting on page 13. Number t f services offered I n this Attachment C (max 5): You may complete another Attachment Cif you h; ie mre than 5. 3 f g the servkc Service #1 Name: SECTION 2 — Service Name(s) and Information is nthlyf packa e, pletas rff =-�r c efferent levels. All m nthly state a spedflc minim um nil ; b r if tir ct service hours. acka ust Sex offense Specific/Psychosexual Evaluations 2.1a " ; odalities, curriculum, tools used in delivery of service (D '4 �V� T list c `.f mpany history; DO use bullet points): Use psych f SOMB Standards and Guidelines, clinical interview, risk assessments (SOTIPS, VASOR-II, JSOAP-II, CPORT, etc.), and lsgical and sexual funct ning assessments. 2.1b Anticipated frequency of direct service time administrative time, cjverhead, or travel tim Ste ith the client/family per week, not including professional staffing tite, Leo 4 hours/week). If the service has lrvels, be specific for each level: Typically, one four to five -hour appointment 2.1c Anticipated duration of service (i.e. 34 months): One appointment 2.1d Three (3), or m re, specific goals of the service (DO use bullet points): The goal of a psychosexual evaluation is to determine risk level, determine appropriate level of supervision, inform treatment planning, and to identify any other services that help set the client up for success. 2.1e Three (3), or more, specific outcomes of service: A psychosexual evaluation will identify a risk level and/or risk factors, an appropriate lev well as a prpitsed treatment plane l of supervision/1c ntainment, as 2.1f Target population of the service, including age and gender: Males and females (ages 10+) 2.1g Languages ser ice is available in (pi ase list proficiency and if interpreter services are available): English and Spanish — fluent can speak, read, and write in both languages. 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in wh r in part: No Service #2 ame: Boundaries Course 2.2a M*dalities, curriculum, tools used in delivery of service (DO NOT list company hist ry; DO us bullet points): Sex Offense Treatment topics including appropriate boundaries, healthy relationships and healthy sexuality, cnsent, communication, emotion management, decision making and problem -solving skills, impulse control, empathy, csg itive distortions and reframing distorted thinking, and self-esteem. 2.2h Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, : verhead, or travel time (i.e. 4 hurs/week). if the service has levels, be specific fr ..ach level: Once a week for 45-50 minutes session if individual or one hour once a week in group. 2.2c Anticipated durati:•,n f service (i.e. 3-4 months): Typically, 12 weeks but can be longer depending on the client's needs and determination of the MDT/CST: 2.2d Three (3), or more, specific goals of the service (DO use bullet points): The goal 4 Bundaries Treatment is to develop a thorough understanding of healthy and appropriate boundaries in any and all relationships (i.e. romantic relationships, familial relationships, professional relationships). In addition to learning about boundaries, the client : ill learn basic life skills (e.g. communication, thinking errors, accountability, etc.) that will help facilitate the process of identifying, respecting, and enforcing appropriate boundaries. Furthermore, the gta.il is that the client wi9l demonstrate internalization of the Boundaries curriculum through daily life application. 2.2e Three (3), or more, specific outcomes of service: As noted above, it is crucial that the client not only show an understanding .Df the Boundaries curriculum but also demonstrate they have internalized treatment topics and can apply such knowledge to n.:•vel situations. The client should be able to show how they will apply the skills they have learned in treatment. REV. NOV 2020 1 ATTACHMENT C - PR O SA L 2.2f Targ t population ,•;f the service: Males and females (ages 10+) 2.2g Languages service is avail CEP bI in (please list pr ficiency and if interpreter servic s are available): English and Spanish m fluent can speak, read, and write in both languages. 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in wh le or in part: NO Service #3 Na It' eB 0 Inf-rmed Supervise i n Training 2.3a °\iiodalities, curriculum, tools used in delivery of service (DO NOT list c rnpany hist ry; DO use bullet p ints): SOM[B Standards and Guidelines, Family Safety Contract, Chaperone Responsibility Statement. 2.3b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week)° if the service has levels, be specific for each level: One — two hours 2.3c Anticipated durati n of service (i.e. 3-4 months): Typically, the training is a 2 hour appointment. 2.3d Three (3), or more, specific goals of the service (DO use bullet points): The g al of Infrmed Supervision training is tprovide the client with information regarding the f• II wing topics: SCAM Hist`:;ry and Principles, line of sight and supervisi,•:n and child contact, safety planning, risk factors and triggers, underlying factors of sexual offending, responsibility and victim impact, the behavior chain, empathy, gr• oming, consent, rational for informed supervision, how to encurage and model healthy behaviors, and responsibilities of an informed supervisor. The client will also learn the different types of treatment that may be reconmmended and potential expectations of treatment/supervision. 2.3e Three (3), or more, specific outcomes of service: For the client to demonstra to an understanding of the aforementioned topics as well as an expressed willingness to have open and honest communication with the MDT/CST. The client shall express th sir willingness to be an informed supervisor and be „'tilling to adhere to the rules/restrictions. The client shuld be willing to not only supprt the identified patient but also be able to hold them accountable and/or intervene if needed. 2.3f Target population of the service: Males or females 12+ 2.3g Languages service is available in (please list pr ficiency and if interpreter services are Ni vailable): English and Spanish o fluent can speak, read, and write in both languages. 2.3h Medicaid eligibility® list wh Service #4 Name: ther the service is eligible for Medicaid in whole or in part: 2.4ca Modalities, curriculum, tools used in delivery f service (D N T list company hist ry; DO use bullet points): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, erhead, or travel time-, (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3), or more, specific goals of the s r 'Jr ice (DO use bullet points): 2.4e Three (3), or morn specific outcomes of service: 2.4f Target population of the service: g Lang ages service is available in (please list proficiency and if interpreter services ar available): 2.4h Medicaid eligibility o list whether the service is eligible for Medicaid in whole or in part: Servke #5 Name: 2.5a Modalities, curriculum, tools used in delivery of service NOT list company history; DO use bull t points): REV. NOV 2020 2 ATTACHMENT C {' ROPOSAL 2.5b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c Anticipated duration of service (i.e. 3-4 m nths): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: 2.5g Languages service is available in (please list proficiency and if interpreter services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part Section 3 — Service Access and Transportation 3.1 Will you charge Weld County for transporting clients or mileage? Ch:- ck one: 3.2 Will you conduct services in a clfrnt°s hme or in the c rnmunity? Check one: 33 Will you transport cli nts to and/r from services? Check ne: YES 3.4 How many miles are you willing to travel round trip? List a specific number miles. 3.5 When you calculate mile - e, what is ysur starting point address? YES II NO YES NO 120 Miles NO 4689 W 20th St, Greeley, CO SE TION 4 - SERVICE RATES All rates need to include administrative work (Le. 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 h}. surly rates complete section(s) 4®1=405® For monthly rates complete section 4060 • For Home study providers complete section 4,70 For monitored sobriety testing providers complete section 4®8 4.1 H urly Service #1 Name: 4.1a Sex Offense Specific/Psychosexual Evaluations In-Office/Video: 4.1b In -Office with Transportation: In -Home or C�*rnmunity: 4.1c FTM, T®M, Prof. Staffing: 4.1d Nt show: 4.1e Mileage rate: $ Amount 1,000 1,000 120 200 .56 Unit Type per Evaluation per Hour per Hour per Hour per No Sho per Mile C No. of miles included in rate: No. of miles included in rate: 20 This is paid after the miles listed above. miles miles 402 urly Service #2 Name: Boundaries Course 402a In-Office/Video: 4.2b In -Office with Transportation: 4.2c In -Home or Community: 4.2d FTM, T®M, Prof. Staffing: $ Amount 120 CO a 120 Unit Type per Hour per Hour per Hour per Hour No.:•:f miles included in rate: No. of miles included in rate: 0 miles miles REV. NOV 2020 3 C MENT C P 4.2e 4.2f N o s h Mileage rate: 120 per No Sh�••v per Mile This is paid after the miles listed above. 43 Hourly Service #3 Name: 4.3a 4.3b 4.3c 4.3d 4.3e 4.3f Informed Supervision Training InnOffice/@lid In -Office with Transportation: In-H:me i•3r Community: FTM, T M, Pr if. Staffing: No show: Mileage rate: $ Amount 150 MIMEO 120 150 Unit Type per Hour per Hour per Hour per Hour per No Shw per Mile No. of miles included in rate: No. of miles included in rate: This is paid after the miles listed above. miles miles 4.4 H • urly Service #4 Name: 4.4a In-Office/Video: 4.4b In -Office with Transportation: In -Home or Community: 4.4c FTM, TDM, Prof. Staffing: 4.4d N:• show: 4.4e Mileage rate: $ Amount Unit Type per H, ur per Hour per Hour per Hour per No Sh.:w per Mile No. of miles included in rate: N o. I,f miles included in rate: This is paid after the miles listed ab miles miles 4.5 H rig tidy Service #5 Name: 4.5 405b 4.5c 4.5d 4.5e 4.5f In-Office/Video: ffice with Transportation: In -Home or Community: FTM, TDM, Prof. Staffing: show: Mileag rate: iii $ Amount Unit Type per Hour per Hour per Hour per Hour per No Sho per Mile N o. of miks included in rate: N o. of miles included in rate: This is paid after th miles listed above. iles miles • 4.6 Mo nthly Service Rates (each level must be listed): 4.6a 4e6b 4.6c 4.6d 4.6e 4.6f 4.6g 4,6h 4.6i 4.6j Service Name with Level Rate per Month N of Direct Service Hours: 43 Home Study Providers — List your rates hi the box below. 4.8 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: In Section 3, I checked the box indicating I will provide services in the community, which includes group homes and/or detention facilities. It should be noted evaluations can be provided in the community but not ongoing therapy. Additionally, I do not provide IN -HOME services. REV. NO 2020 4 ATTACHMENT D - STAFF DATA SHEET Bidder Must List All Staff Who Will Administer the Proposed Service(s) BIDDER'S LEGAL NAME (As it appears on the W-9): Northern Colorado Counseling & Assessment, LLC AGENCY CONTACT: Christina Rascon PHONE NUMBER: 720-588-0565 EMAIL: dr.rascon@nococounseling.co PROPOSED SERVICE(S): Mental Health Services and Sexual Abuse Treatment Rascon Middle Previous Legal Last Initial Name (If applicable) C Legal First Name Nora Service Type treatment provider/evaluator Licensuref Credentials Licensed Clinical Psychologist DORA # (If applicable) PSY.0005167 CHILD WELFARE REQUEST FOR PROPOSAL 2021-22 - VARIOUS SERVICES BID NO. B2100042 AC N' CERTIFICATE OF LI ILITY INSURANCE DATE(MM/DD/YYYY) 08/06/2020 THIS CERTIFICATE OS ISSUED AS A MATTER F INFRM��Tl��N ONLY AND C NIFErS N,+•i RIGHTS UPON THE CERTIFICA E HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE MOLDER. I v�PORTAbfl: Of the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONA INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject t the terms and conditions of the poDiccy, certain policies may require an endorsement. A statement on this certificate does not cconhrr rights tt the certificcatt holder in lieu of such endorsementLs) PRODUCER Trust Risk Mana• ement Services, Inc. doing business in CO as Potomac Risk Management Services, Inc. 1791 Paysphere Circle Chicago, IL 60674 INSURED Nora Rascon 3231 Ellis Ct Evans, CO 80620 3419 CONTACT NAME: Trust Risk R O anaclement Services, Inc PHONE (A/C, No, Ed): 877.637.9700 EMAIL ADDRESS: info@trustrms.com FAX (A/C, No): 877.251.5111 INSURER(S) AFFORDING COVERAGE INSURER ACE American Insurance Company INSURER B: NAIC # 22667 INSURER C: INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NU o ERe THIS IS TO CERTIFY THAT THE POLICIES OF PERIOD INDICATED. NOTWTHSTANDING ANY TO WHICH THIS CERTIFICATE MAY BE ISSUED TO ALL THE TERMS, EXCLUSIONS AND COND INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V\fITH RESPECT OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUB VWD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LI i,BILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per Person) $ BODILY INJURY {Per accident $ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ O :KERS COMPENSATION ANL EMPLOYERS LIABILITY Y1 N ANY PROPRIETOR/PARTNER/EXECUTIVE N / A PER STATUTE 0TH- ER $ E.L.EACH ACCIDENT $ E_L. DISEASE -EA EMPLOYEE OFFICER/MEMBER {Mandat®ry in NH) If yes, describe under EXCLUDED? E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below A Psychologist's Liability Retroactive Professional Date: 11/09/2018 58G28659167 11/09/2019 11/09/2020 Each Annual Aggregate Incident $1,000,000 X3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I Board of County Commissioners of Weld VEHICLES ( CORD 101, Additional Remarks County and It's officers/employees Schedule, may be attached if more space is required): CERTIFICA ITE HOLDER CANCELLATION Weld County 1150 0 Street Greeley, CO, 80631 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE ILL BE DELIVERED IN ACCORDANCE WITH THE PLICY PR VISISNS. O AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988=2015 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered rm rks of CORD EXHIBIT C SCOPE OF SERVICES Contractor will provide Mental Health Services and Sexual Abuse Treatment, as referred by the Department. Mental Health Services 1. Mental Health Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Clinical interview. ii. Linited testing including mini mental status, brief personality inventory, and a symptom inventory. b. Anticipated Frequency of Services: i. One (1) appointment for three (3) to four (4) hours. c. Anticipated Duration of Services: i. One (1) time. d. Goals of Services: i. To gain a greater understanding of the client's mental health functioning including: 1. Presence of any mental health symptoms/disorders. 2. How the symptoms are impacting the client's functioning. 3. How to best address the client's mental health concerns. e. Outcomes of Services: i. A report that addresses any mental health symptoms the client may be experiencing. ii. Recommendations for an appropriate treatment plan. iii. Identification of other services such as mentoring and family therapy that the client may benefit from. f. Target Population: i. Ages 10 and older. ii. Male and female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor will not transport clients. ii. Contractor is willing to travel up to 120 miles round-trip from the starting location of: 4689 West 20th Street, Suite E, Greeley, Colorado 80631. 2. Psychological Evaluation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Clinical interview. ii. Multiple questionnaires and inventories related to personality, trauma, and substance use. 1 iii. Projective assessments including the Thematic Apperception Test and Rorschach Inkblot Test. iv. IQ/Cognitive functioning testing. v. Memory testing. vi. Malingering/effort testing. vii. Coordination with other professionals such as the client's therapist, probation officer, or significant other to obtain collateral information regarding the client's functioning. viii. Each assessment is designed to meet the client's specific needs and ensure the referral question is answered. b. Anticipated Frequency of Services: i. One (1) four (4) to six (6) hour testing session per week. Testing time will vary depending on the case. c. Anticipated Duration of Services: i. Typically, two (2) testing sessions. d. Goals of Services: i. Provide a wholistic picture of the client including their mental health functioning, personality structure and how they interpret/perceive themselves, the world, and others. ii. Provide information regarding the client's cognitive functioning and whether or not they are able to function and/or meet the expectations set for them. iii. If memory is a concern, testing could determine if the client has true deficits in memory. Furthermore, a psychological evaluation could include malingering testing to determine if the client is feigning or exaggerating symptoms. e. Outcomes of Services: i. A report that identifies: 1. The client's current level of functioning including mental health symptoms or any diagnosis that may be present. 2. A proposed treatment plan. 3. Identification of other services the client may benefit from that would help set them up for success. f. Target Population: i. Ages 10 and older. ii. Male and female., g. Language: i. English and Spanish h. Medicaid Eligibility: i. This service is not Medicaid eligible. Service Access and Transportation: i. Contractor will not transport clients. ii. Contractor is willing to travel up to 120 miles round-trip from the starting location of: 4689 West 20th Street, Suite E, Greeley, Colorado 80631. 3. Consultation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Modalities, curriculum, and tools will be determined based upon the needs of the referral source. 2 ii. Contractor will utilize her professional expertise in the Sex Offender Management Board (SOMB) field and knowledge as it relates to clinical psychology. b. Anticipated Frequency of Services: i. As needed. c. Anticipated Duration of Services: i. As needed. d. Goals of Services: i. PFovide Department employees guidance in how to best accommodate a client or handle the current case. e. Outcomes of Services: i. Department employees would gain guidance on how to best accommodate a client or handle the current case. f. Target Population: i. Department employees. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. Service Access and Transportation: i. Contractor will not transport clients. ii. Contractor is willing to travel up to 120 miles round-trip from the starting location of: 4689 West 20th Street, Suite E, Greeley, Colorado 80631. Sexual Abuse Treatment 4. Sex Offense Specific/Psychosexual Evaluations a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Sex Offense Management Board (SOMB) Standards and Guidelines. ii. Clinical interview. iii. Risk assessments: 1. Sex Offender Treatment Intervention and Progress Scale (SOTIPS). 2. Vermont Assessment of Sex Offender Risk -II (VASOR-II). 3. Juvenile Sex Offender Assessment Protocol -II (JSOAP-II). 4. Child Pornography Offender Risk Tool (CPORT). 5. As well as psychological and sexual functioning assessments. b. Anticipated Frequency of Services: i. One (1) four (4) to five (5) hour appointment. c. Anticipated Duration of Services: i. One (1) time evaluation. d. Goals of Services: i. Determine client's risk level. ii. Determine client's appropriate level of supervision. iii. Inform client's treatment planning. 3 iv. Identify any other services that help set the client up for success. e. Outcomes of Services: i. Identify client's risk level. ii. Identify an appropriate level of supervision/containment. iii. Propose a treatment plan. f. Target Population: i. Ages 10 and older. ii. Male and female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor will not transport clients. ii. Contractor is willing to travel up to 120 miles round-trip from the starting location of: 4689 West 20th Street, Suite E, Greeley, Colorado 80631. 5. Boundaries Course a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Sex Offense Treatment topics including appropriate boundaries, healthy relationships and healthy sexuality, consent, communication, emotion management, decision making and problem -solving skills, impulse control, empathy, cognitive distortions and reframing distorted thinking, and self-esteem. b. Anticipated Frequency of Services: i. Individual: One (1) time per week for 45-50 minutes. ii. Group: One (1) time per week for one (1) hour. c. Anticipated Duration of Services: i. Twelve (12) weeks. d. Goals of Services: i. Develop a thorough understanding of healthy and appropriate boundaries in any and all relationships such as romantic relationships, familial relationships, and professional relationships. ii. While learning about boundaries, the client will learn basic life skills such as communication, thinking errors, and accountability that will help facilitate the process of identifying, respecting, and enforcing appropriate boundaries. iii. Client will demonstrate internalization of the Boundaries curriculum through daily life application. e. Outcomes of Services: i. Client will show an understanding of the Boundaries curriculum and demonstrate they have internalized treatment topics and can apply such knowledge to novel situations. ii. Client will show how they will apply the skills they have learned in treatment. f. Target Population: i. Ages 10 and older. ii. Male and female. 4 g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor will not transport clients. ii. Contractor is willing to travel up to 120 miles round-trip from the starting location of: 4689 West 20th Street, Suite E, Greeley, Colorado 80631. 6. Informed Supervision Training a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Sexual Offence Management Board (SOMB) standards and guidelines. ii. Family safety contract. iii. Chaperone responsibility statement. b. Anticipated Frequency of Services: i. One (1) to two (2) hours. c. Anticipated Duration of Services: i. One (1) training appointment. d. Goals of Services: i. To provide the client with information regarding the following topics: SOMB History and Principles, line of sight and supervision and child contact, safety planning, risk factors and triggers, underlying factors of sexual offending, responsibility and victim impact, the behavior chain, empathy, grooming, consent, rational for informed supervision, how to encourage and model healthy behaviors, and responsibilities of an informed supervisor. ii. Client will also learn the different types of treatment that may be recommended and potential expectations of treatment/supervision. e. Outcomes of Services: i. Far the client to demonstrate an understanding of the topics listed under "goals of services" as well as an expressed willingness to have open and honest communication wlh the Multidisciplinary Team (MDT)/Community Supervision Team (CST). The client shall express their willingness to be an informed supervisor and be willing to adhere to the rules/restrictions. The client should be willing to not only support the identified patient but also be able to hold them accountable and/or intervene if needed. f. Target Population: i. Ages 18 and older. ii. Male or female. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Contractor will not transport clients. 5 ii. Contractor is willing to travel up to 120 miles round-trip from the starting location of: 4689 West 20th Street, Suite E, Greeley, Colorado 80631. Terms 1. Contractor will respond to the Quality Assurance Team (HS-CWQualityAssurance(a weldgov.com within three (3) business days regarding the ability to accept the received referral. 2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team HS - C WQu alitvAssu rance(aweldgov.com. 3. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or 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(aweldgov.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. 6 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 sleeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filing 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(a,weldeov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Departmert of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 7 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 Mental Health Services Rate Unit Type Service Name $150.00 Hour Consultation $120.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professionals Staffing $600.00 Episode Mental Health Evaluation $0.56 Mile Mileage, for distances exceeding 20 miles from 4689 West 20th Street, Greeley, Colorado 80634 $200.00 Each No Show $350.00 Hour Psychological Evaluation Sexual Abuse Treatment Rate Unit Type Service Name $120.00 Hour Boundaries Course $120.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professionals Staffing $150.00 Hour Informed Supervision Training $0.56 Mile Mileage, for distances exceeding 20 miles from 4689 West 20th Street, Greeley, Colorado 80634 $120.00 Each No Show - Boundaries Course $150.00 Each No Show - Informed Supervision Training $200.00 Each No Show - Psychosexual Evaluation $1,000.00 Episode Sex Offense Specific/Psychosexual Evaluations 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. Contract Form New Contract Request Entity e * NORTHERN COLORADO COUNSELING & ASSESSMENT LLC Entity ID* @00042695 Contract Name* NORTHERN COLORADO COUNSELING & ASSESSMENT LLC (CHILD PROTECTION AGREEMENT) Contract Status CTB REVIEW tract Description* BID# 82100042. TERM: 6/1/21-5,131 ❑ New Entity? Contract ID 4794 Contract Lead* APEGG Contract Lead Email apegg@weldgov.com, c©bbx xlk@weldg©v.com Contract Description 2 MEMO WAS PRESENTED TO THE BOCC BY PURCHASING ON 4 7,3`2021 TYLER ID: 2021-0307. Contract Type* AGREEMENT Amount* $0.00 Renewable* YES Automatic Renewal Department HUMAN SERVICES Department Email CM- HurnanServices@weldgov.co m Department Head Email CM-HumanServices- De pt H ead Cave I d g ov. cony County Attorney GENERAL COUNTY A l I ORNEY EMAIL County Attorney Email CM- COUNTYA I I ORNEY@WELDG OV.COM Requested BOCC Agenda Date* 05/26;2021 Parent Contract ID 20210307 Requires Board Approval YES Department Project Due Date 05122;'2021 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates D. Notice Period Co act It�fcx iwi Contact Info T' Purchasing Review Date" 04/01/2022 Committed Delivery Date Renewal Date* 05/31/2022 Expiration Date Contact Phone 1 Contact Phone 2 Purchas` r Purchasing Approved Date CONSENT 05/24 2021 Approval Proces' Department Head JAMIE ULRICH OH Approved Date 05/24,?2021 Final Appri BOCC Approved BOCC Signed Date BOCC Agenda Date 06x02/2021 Originator APEGG Finance Approver CONSENT Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 05/24/2021 05 x24/2021 Tyler Ref # AG 060221 Hello