The URL can be used to link to this page

Browse Search

Home My WebLink About20201214.tiff(j)y*0, C+ I t)g oioq PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: July 12, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services N T Y ' RE: Amendment #3 with Polaris Partners Counseling and Consulting 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 Amendment #3 with Polaris Partners Counseling and Consulting LLC. On April 27, 2020, the Department entered in a Child Protection Agreement with Polaris Partners Counseling and Consulting LLC for Intensive In -home Therapy. This Agreement is known to the Board as Tyler ID 2020-1214. The Agreement was amendment on May 3, 2021 to amend the Exhibit D, Rate Schedule, and extend the term date through May 31, 2022. The Agreement was amended once again on May 18, 2022 to extend the term date through May 31, 2023. The Agreement is now being amended to update the Exhibit D, Rate Schedule as shown below. Intensive In -Home Therapy— Individual or Family - English: Rate Unit Type Service Name $1325.00 Hour Out of Office $1325.00 Hour Family Team Meeting,Team Decision Making, Professional Staffing $1325.00 Hour Telehealth $60.00 RoundTrip Na Show $0.56 Mile For distance exceeding thirty (30) miles from practitioner's office located at 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. I do not recommend a Work Session. I recommend approval of this Amendment and authorize the Chair to sign. Approve Schedule Recommendation Work Session Other/Comments: Perry L. Buck �` Mike Freeman, Pro -Ter Scott K. James, ChairX-2-M Steve Moreno LoriSaine Pass -Around Memorandum; July 12, 2022 - CMS ID 6109 Page 1 Y-€' -'- &4"O1I)) ci20 — I AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND POLARIS PARTNERS COUNSELING AND CONSULTING, LLC. n .., This Agreement Amendment, made and entered into W..`day of ,2522 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Sery es, hereinafter referred to as the "Department", and Polaris Partners Counseling and Consulting, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Intensive In -Home Therapy, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2020-1214, approved on April 27, 2020. 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, 2021. • The Original Agreement was amended on: • May 3, 2021 to amend the Exhibit D, Rate Schedule, and extend the term date through May 31, 2022. • May 18, 2022 to extend the term date through May 31, 2023. • The Amendment is also identified by the Weld County Clerk to the Board of County Commissioners as document number 2020-1214. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement effective June 1, 2022: 1. Exhibit D, Rate Schedule, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. `�i�cr�l C/• �p��, COUNTY: ATTEST: BOARD OF COUNTY COMMISSIONERS lerk to the B WELD OUNT , COLORADO BY: Deputy Cl tot co . James, Chair JUL 2 O 2022 ` Polaris Partners Counseling and Consulting, LLC. 300 East Horsetooth Road, Suite 200 Fort Collins, Colorado 80525 .off By: Victoria Ger er, LPC (Jun 27, 2022 10:24 MDT) Victoria Gerber, Co-owner Jun 27, 2022 Date: o2' -/r2/4'/ 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 Intensive In-H)rprppy- Individual or Family - English: Rate Unit T e Service Name $135.00 Hour Out of Office $135.00 Hour Family Team Meeting, Team Decision Making, Professional Staffing $135.00 Hour Telehealth $60.00 Round Tri No Show $0.56 Mile For distance exceeding thirty (30) miles from practitioner's office located at 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. Intensive In-Hrppy- Individual or Family — Bilingual/Spanish: Rate Unit T e Service Name $240.00 Hour Out of Office $240.00 Hour Family Team Meeting, Team Decision Making, Professional Staffing $240.00 Hour Telehealth $60.00 Round Tri No Show $0.56 Mile For distance exceeding thirty (30) miles from practitioner's office located at 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. New Contract Request Entity Information Entity Name* Entity ID ❑ New Entity? POLARIS PARTNERS LLC @00036707 Contract Name* Contract ID, Parent Contract ID POLARIS PARTNERS LLC (AMENDMENT 3) 6109 20201214 Contract Status Contract Leada Requires Board Approval CTR REVIEW CC YES Contract Lead Email Department nt Project apegg6weldgovcom-1cobbx xIk_ eldgov.corrr Contract Description* CONSENT : ENDMENT TO UPDATE THE RATE SCHEDULED. Contract Description 2 PA IS REINS ROUTED THROUGH THE NORMAL PROCESS. ETA TO CTR14!22. Contract Type* Department Requested nda Due Date AMENDMENT HUMAN SERVICES Date* 07 15 2022 0712012022 Amount* Department Email $0.00 CM Will a work session with 110CC be required?* HurnaaServices _ - el gov.co NO Renewable* rra NO Does Contract require Purchasing Dept. to be inclu Department Head it Automatic Renewal CM-HumanSermces OeptHeau@weIdgov.com Grant County Attorney GENERAL COUNTY IDA ATTORNEY EMAIL County Attorney Email CM- COU A ORNEY@LDC OSICOM If this is a renewal enter previous Contract ID If this is part of a NSA enter MSAContract ID Note: the Previous Contract Number and Master Se aces Agreement Number should be left blank if those contracts are 9O1 19 On Rase Contract Dates Effective Review Date* Renewal Date 04;'03, 2023 Termination Notice Period coxnrrutteol Delivery Date Expiration Date's 05 31:'2023 Contact Information ntact Info , contact Name Contact Type Contact Emil Contact Phone 1 Contact Phone 2 Purchasing Purchasing rover Purchasing Approved Date CONSENT 07101 ; 2022 Approval Process Department Head Finance Approver Legal Counsel JAMIE ULRICH CONSENT CONSENT DH Approved Date Finance Approved Date Legal Counsel Approved Date 0701 t'2022 07101 12022 07,'`01,`2322 Final Approval 80CC Approved Tyler Ref# AC 072022 10CC Signed Date 110CC Agenda Date 07 (20x' 2022 Originator APECC �,varr � btk Sgzs PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 29, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2020-21 Core/Non-Core Contracted Services B2000037 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 2020- 21 Core/Non-Core Contracted Services B2000037. The Department entered into Agreements with various Child Welfare service providers through the 2020-2021 Request for Proposal (RFP), Bid Number: B2000037, identified as Tyler ID 2020-0373. 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 eight (8) providers reflected in the attached list. Agreements will be renewed for the third 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. Approve Recommendation Perry L. Buck Mike Freeman, Pro -Tern YY\ Scott K. James, Chair Steve Moreno Lori Saine __ Schedule Work Session Other/Comments: Pass -Around Memorandum; March 29, 2022 — CMS ID — Various Page 1 20Zc iZ22 a5A g 2 PRIVILEGED AND CONFIDENTIAL 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 O Street PO Box 758 Greeley CO 80632 Phone: 970-400-4205 Fax: 970-336-7233 Email: Isaine@weldttov.com Website: www.co.weld.co.us In God We Trust Lori Saine Tuesday, March 29, 2022 11:33 AM Karla Ford RE: Please Reply - PA FOR ROUTING: CW Core Non -Core 2020-21 Renewals B2000037 (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 10:44 AM To: Lori Saine <Isaine@weldgov.com> Subject: Please Reply - PA FOR ROUTING: Importance: High CW Core Non -Core 2020-21 Renewals B2000037 (CMS Various) Please advise if you approve recommendation. Thank you. Karla Ford X Executive Assistant & Office Manager, 1150 O Street, P.O. Box 758, Greeley, :: 970.336-7204 :: kfordOweldgov.con **Please note my working hours are Board of Weld County Commissioners Colorado 80632 1:: www.weldgov.com :: Monday -Thursday 7:00a.m.-5:00p.m.** ,� to r ' AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND POLARIS PARTNERS COUNSELING AND CONSULTING, LLC. This Agreement Amendment, made and entered into day of ► l , 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department", and Polaris Partners Counseling and Consulting, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Intensive In -Home Therapy, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2020-1214, approved on April 27, 2020. 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, 2021. • The Original Agreement was amended on: • May 3, 2021 to amend the Exhibit D, Rate Schedule, and extend the term date through May 31, 2022. • The Amendment is also identified by the Weld County Clerk to the Board of County Commissioners as document number 2020-1214. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for the third and final year, for the period of June 1, 2022 through May 31, 2023. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. �� COUNTY: ATTEST: ' BOARD OF COUNTY COMMISSIONERS lerk to the Bo WE COUNTY, COLORADO BY: �Le Deputy Cler m t O S K. James, Chair MAY 18 2022 CONTRACTOR: Polaris Partners Counseling and Consulting, LLC. 300 East Horsetooth Road, Suite 200 Fort Collins, Colorado 80525 W2 o is 5 tbei L �C By: Victoria Gerber, LPC (May 12, 2022 15:45 MDT) Victoria Gerber, Co-owner May 12, 2022 Date: Gov -/A/$ New Contract Request Entity Information Entity Namet Entity 1D* POLAR S PARTNERS LLC x00036707 Contract Name * POLARIS PARTNERS LLC (AGREEMENT AMENDMENT PY 2022-23) Contract Status CTB REViEW Contract Description* B1D# 132000037, TERM 6/1/22-5/31123. Contract Description 2 CONSENT: PA WAS SENT TO CTi3 ON: 3/3012022 Contract Type* Department AMENDMENT HUMAN SERVICES Amount* it Department Email $0.00 CM- HumanServpiceseldgov.co Ste able * m NO Department Head it Automatic Renewal CM-HumariServices- DeptH'ead 9 eldgov.corn Grant County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WELDG OV, COM if this is a renewal enter previous Contract ID If this is partofaMsAenterMsAContractlD ❑ New Entity? Contract ID 5825 Contract Lead* APEGG Contract Lead Email apeggL eldgov.com;cobbx xlk weldgov.core Parent Contract ID 20201214 Requires Board Approval YES Department Project I Requested ROCC Agenda Due Date Date* 0521/2022 05/2512022 Will a work session with BOCC be required?* NO 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 * Renewal Date 04i032023 Termination Notice Period Committed Delivery date Expiration Date* 05312023 Contact Information Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Purchasing Purchasing r CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 05/13/2022 Final Approval r OCC Approved C Signed Date BOC Agenda Date 05/18/2022 Originator APEGG Purchasing Approved Date 05 13,='2022 Finance Approver CONSENT Finance Approved Date 05,`1312022 Tyler Ref # AG 051822 Contact Phone 2 Legal Counsel CONSENT Legal Counsel Approved Date 05/1 3 2022 PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: April 27, 2021 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment with Polaris Partners Counseling and Consulting, 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 with Polaris Partners Counseling and Consulting, LLC. The Department entered into a Child Protection Agreement for services with Polaris Partners Counseling and Consulting, LLC, identified as Tyler ID 2020-1214 on April 27, 2020. The Agreement is being amended to renew for a second year, for the period of June 1, 2021 through May 31, 2022 and to make changes to the Rate Schedule as noted below. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Rate Schedule Changes: Intensive In -Home Therapy — Individual or Family - English: 13 3 44Q/l �trt-(Out -4fter-1 1' a{)0lhour Out pi' ()ffic OEli lzntr 3 l 1 4; I +f 4 +tt ?`125 UO/ltous (.Family "I'eatn Meeting (FTMZTeam Decision Making (TDM) Meetini'.PPt+(Professional Staffing) $125.00/IIourj' c.hcalth Intensive In -Home Therapy — Individual or Family — Bilingual/Spanish: $240.00/i- o lr(Tclelhcttlt ) Pass -Around Memorandum; April 27, 2021 — ID 4697 Page 1 �' �a'QiC�l O + - �O`o�O101 n �� hlROoga PRIVILEGED AND CONFIDENTIAL I do not recommend a Work Session, I recommend approval of this Agreement Amendment, Approve Recommendation Perry L. Buck Mike Freeman Scott K. James, Pro -Tern Steve Moreno, Chair Lori Saine Schedule Work Session Other/Comments: Pass -Around Memorandum; April 27, 2021 - ID 4697 Page 2 8 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND POLARIS PARTNERS COUNSELING AND CONSULTING, LLC. rd This Agreement Amendment, made and entered into Ll day of. 2021 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Huma/ Services, hereinafter referred to as the "Department", and Polaris Partners Counseling and Consulting, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Intensive In -Home Therapy, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2020-1214, approved on April 27, 2020. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement will end on May 31, 2021. • 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: Term This Agreement is being renewed for a second full year term, for the period of June 1, 2021 through May 31, 2022. 2. Exhibit D, Rate Schedule, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. 300 East Horsetooth Road, Suite 200 Fort Collins, Colorado 80525 By: Victoria M Gerber (Apr 15, 202110:48 MDT) Victoria Gerber, Co-owner Date: Apr 15, 2021 oZo�o ./02/7L 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 Intensive In -Home Therapy — Individual or Family - English: Rate Unit Type Service Name $125.00 Hour Out of Office $125.00 Hour Family Team Meeting, Team Decision Making, Professional Staffing $125.00 Hour Telehealth $60.00 Round Trip No Show $0.56 Mile For distance exceeding thirty (30) miles from practitioner's office located at 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. Intensive In -Home Therapy — Individual or Family — Bilingual/Spanish: Rate Unit Type Service Name $240.00 Hour Out of Office $240.00 Hour Family Team Meeting, Team Decision Making, Professional Staffing $240.00 Hour Telehealth $60.00 Round Trip No Show $0.56 Mile For distance exceeding thirty (30) miles from practitioner's office located at 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. 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 7"' day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. New Contract Request Entity Information Entity Tame * Entity I'D * POLARIS PARTNERS LLC: 0003670? Contract Name * POLARIS PARTNERS LLC (AGREEMENT AMENDMENT) Contract Status CTB REVIEW Contract Description BID #B2000037 TERM 6 1 .21-5, 31 x`22. Contract Description 2 CONSENT, PA WAS SENT TO CTB ON 3/31/21. 1-1 New Entity? Contract ID 4697 Contract Lead AP"EGG Contract Lead Email apegg@weldgovcom:cobbx xlk'-a weldgov.corn Parent Contract ID 20201214 Requires Board Approval YES Department Project # Contract Type Department Requested BOCC Agenda Due Date AMENDMENT HUMAN SERVICES Date* 05122/2021 05126.2021 Amount * Department Email 0,00 Cm- Will a work session with BOCC be required?* HumanServicesc veldgov.co NO Renewable * NO Does Contract require Purchasing Dept. to be included? Department Head Email Automatic Renewal CI9-Human5ervices- DeptHea+d %,eldcg. ov,con Grant County Attorney GENERAL COUNTY IGA ATTORNEY EMAIL County Attorney Email C1- C.OLI NTY"ATTO RN EY@WELDG OV.COM if this is a renewal enter previous Contract ID if this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On Base Contract Dates Effective Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process. Department Head JAMIE ULRICH DH Approved Date 04,' 19 2021 Final Approval &)CC Approved EOCC Signed Date BOCC Agenda Date 0503;'2021 Originator APEGG Review Date 04/01/2022 Committed Delivery Date Renewal Date Expiration Date , 053112022 Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Approved Date 04;i92021 Finance Approver CONSENT Finance Approved Date 04,191,2021 Tyler Ref # . G 050321 Legal Counsel CONSENT Legal Counsel Approved Date 04 1912021 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND POLARIS P RTNERS This Agreement, made and entered into th _ ay 2O2.p, by and between the Board of Weld County Commissioners, on behalf of the Weld County Departme of Human Services, hereinafter referred to as the "Department' and Polaris Partners, 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 B2000037, 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 Child Welfare Administration or other funding to the Department for Intensive In -Home Therapy. 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, 2020, upon proper execution of this Agreement and shall expire May 31, 2021, 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 Supervisor (hainleid@weldgov.com, 970-400-6210). No other Department staff or other party to the case may authorize services or modifications to services. v" 2020-1214 J ��✓�b "T'"o2.% � o� 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 one-time services (ex. home studies, evaluations and monitored sobriety testing). Contractor agrees that original complete Client Verification Forms with original signatures are to be submitted with the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet 60 -day deadline may result in termination of the Agreement. d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service, for each client receiving ongoing services. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Date and time of service b. Where the service took place c. Clinician/therapist name d. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. evaluations, 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. 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. 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 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. 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. seo. and its implementing regulation, 45 C.F.R. Part 80 et. sea•; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and - Title VII of the Civil Rights Act of 1964; and - the Age Discrimination in Employment Act of 1967; and - the Equal Pay Act of 1963; and - the Education Amendments of 1972; and - Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and - all regulations applicable to these laws prohibiting discrimination because of race, color, national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions covered under Section 504 of the 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. 4 e. Public Contracts for Services C.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this contract. Contractor will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E -Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5- 102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to undertake pre -employment screening or job applicants while this Agreement is being performed. If Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contractor shall not terminate the contract if within three days the subcontractor provides 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 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; - 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. 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 8 procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. - Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. - Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s). For Department: For Contractor: Heather Walker. Child Welfare Division Head Victoria Gerber, Co -Owner 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich. Director P.O. Box A Greeley, CO 80632 (970) 400-6581 18. Litigation For Contractor: Victoria Gerber, Co -Owner 300 East Horsetooth Road. Suite 200 Fort Collins, CO 80525 (970) 270-9418 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. seg., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more 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 10 of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage. Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all 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 11 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 Emolovee of Weld Count 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 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 12 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. EmDlovee Financial Interest/Conflict of Interest. C.R.S. §§24-18-201 et seq. and §24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 34. Choice of Law/Jurisdiction Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 36. Attorney's Fees/Legal Costs 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, 13 data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the Department. Contractor shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of the Department. 38. Interruptions Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. 39. Severability If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: �/• a.`s+�4�GC BOARD OF COUNTY COMMISSIONERS We By: DeF 14 'ELD COUNTY, COLORADO ike Freeman, Chair APR 2 7 2020 )NTRACTOR: Polaris Partners 300 East Horsetooth Road, Suite 200 Fort Collins, CO 80525 (970) 270-9418 By: Victoria M. Gerber (Apr 9, 2020) Victoria Gerber, Co -Owner Date: Apr 9, 2020 oow- 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. fiPOLARIS PARTNERS COUNSELING & CONSULTING EXHIBIT B CONTRACTOR'S RESPONSES TO REQUEST FOR PROPOSAL January 22, 2020 Polaris Partners Counseling and Consulting, LLC 300 E. Horsetooth Rd., Ste 200 Fort Collins, CO 80525 866-285-2929 To Whom It May Concern, This letter is to confirm that we, Polaris Partners Counseling and Consulting, LLC, are submitting a bid proposal for Weld County Child Welfare (Bid No. B2000037) for the year 2020-2021. We intend to provide the following services with individual service bid proposals attached for each: - Home Based Intervention o Intensive In -Home Therapy — Individual and Family ■ English and Spanish/bilingual Our providers listed in the accompanying Staff Data Sheets are qualified to provide in - home services to residents of Weld County and we guarantee the "ability to deliver the services as proposed and comply with the specific requirements set forth by Weld County". We also guarantee the "capacity to be organized, responsive and to quickly and successfully schedule services as requested." Please see attached supporting documents requesting the ability to provide mental health services to residents of Weld County. Sincerely, Victoria Gerber, LPC, CACII Co-Owner/Therapist Polaris Partners Counseling and Consulting, LLC victoria.gerber@polarispartnerscc.com 300 E. Horsetooth Rd., Ste 200, Ft. Collins, CO 80525 866-285-2929 info@polarispartnerscc.com ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES - PROVIDER INFORMATION FORM (PIF) Please type your information using the form fields (boxes) below. You can press the Tab key to move from field to field. Agency Information Polaris Partners Counseling and Consulting, LLC Agency Name: Primary Contact Full Name: Eric Wilson Primary Phone Number (10 -digit): 720-232-3459 Ext.: Primary Contact Email: eric.wilson@polarispartnerscc.com Agency Location Address (Street, city, state, zip): Trails Provider ID (if known): Therapist; In -Home Program Supervisor Title: Fax Number (10 -digit): 208-567-5844 www.polarispartnerscc.com Web Address: 300 E. Horsetooth Rd., Ste 200 Fort Collins, CO 80525 Agency Mailing Address (street, city, state, zip): 300 E. Horsetooth Rd., Ste 200 Fort Collins, CO 80525 Agency Type (pick one): F Private 11 Private Non -Profit ® Private for Profit DHS service referrals should be sent to whom in your organization: Referral Contact Name: Eric Wilson Referral Phone Number (10 -digit): 720-232-3459 Ext.: Billing Contact Name: Damond Dotson Billing Phone Number (10 -digit): Billing Contact 970-576-1717 Ext.: Therapist; In -Home Program Supervisor Title: eric.wilson@polarispartnerscc.com Email: Title: Therapist; Co -Owner Email: damonddotson@polarispartnerscc.com m .. .. .. .. .. .. .. .. a. .. .. .. .. .. .. .. .. .. .. .. • . .. • . j CERTIFICATION jI 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 j behalf of the Weld County Department of Human Services, and comply with all requirements of the contract, if awarded. I I The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and j 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 I all cases where the bids are competitive in price and quality. I Authorized Rep. Full Name: Victoria Gerber Title: Therapist; Co -Owner j Authorized Rep. Email: victoria.gerber@poiarispartnerscc.com Phone: 970-270-9418 Ext.: I Authorized Rep. Address: 300 E. Horsetooth Rd., Ste 200 Fort Collins, CO 80525 Digitally signed by Victoria Gerber I Victoria Gerber 1/22/2020 I Signature of Authorized Rep.: Date: 2020.01.22 20:31:11-07'00' Date: I I REV. DEC 2019 ATTACHMENT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1 Provider and Program Area Information Bidder's Legal Name: Polaris Partners Counseling and Consulting, LLC — submitted by Victoria Gerber, LPC (Therapist/Co-Owner) Program Area: Home -Based Intervention Number of services offered on this Exhibit C (max 5): 44 Program Areas are listed in column 1 of the table located in Item XI of the Request You may complete another Exhibit C if you have more than 5. for Proposal starting on page 13, Service #1 Name: SECTION 2 - Service Name(s) and Information Intensive In -Home Therapy - Individual - English 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, therapists will address: • individual patterns of addiction and maladaptive coping • mental health issues and community involvement • all treatment will be individualized and tailored to the specific needs and strengths of the client Evidence -based practices will be used to help client develop skills and ability to • manage mood and behaviors • develop intrinsic motivation to succeed • improve self-control and emotion regulation • develop healthy interpersonal skills • strengthen family and social bonds in addition to other 2.1b Anticipated frequency of service per week (i.e. 4 hou 2 hours per week, per case 2.1c Anticipated duration of service (i.e. 3-4 months): 4 months, with option to renew service if clinically ni 2.1d Three (3), or more, specific goals of the service (DO use bullet points): To help client achieve identified individualized treatment goals around: • improved function • emotional stability • ability to behave appropriately within their communities treatment Polaris Partners providers will collaborate with client's team to ensure client has access to necessary resources for the highest chance of achieving success. Therapists will provide weekly individual therapy as requested by the team and family. All in person contact will be billed the same rate including therapy, team meetings, and court appearances. Other services provided include crisis follow-up availability to youth, family, and teams; coordination and planning with other involved professionals and service providers; treatment plan updates; court updates. 2.1e Three (3). or more. specific outcomes of service: Treatment outcomes depend on many variables, primarily hinging on the ability and willingness of clients to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Although outcomes cannot be absolutely guaranteed, Polaris Partners has always and will continue to strive to meet clients where they are and consistently provide premium quality individualized behavioral health services with the goal being to help client achieve identified treatment goals toward: • improved function • emotional stability • ability to behave appropriately within their communities 2.1f Target population of the service, including age and gender: REV. NOV 2019 1 ATTACHMENT C - PROPOSAL TEMPLATE Polaris Partners serves youth ages 5 to 18 (sometimes younger depending on circumstance), all genders, specializing in at - risk populations. Clients dealing with mental health and substance use issues will be served. Polaris Partners providers also work with families to help create a healthy and functional family system and environment in which the client may thrive. 2.1g La 2.1h Medicaid None service is available in (please list Service #2 Name: ibilitv — list whether the service is and if interpreter services are ava for Medicaid in whole or in part: Intensive In -Home Therapy — Family - English 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, therapists will address: • familial patterns of trauma and dysfunction • individual and familial patterns of addiction and maladaptive coping • family systems and roles • mental health issues and community involvement • all treatment will be individualized and tailored to the specific needs and strengths of the client and family members Evidence -based practices will be used to help client and family develop skills and ability to: • manage mood and behaviors • develop intrinsic motivation to succeed • improve self-control and emotion regulation • develop healthy interpersonal skills • strengthen family and social bonds in addition to other specified treatment 2.2b Anticipated frequency of service per week (i.e. 4 hours/week): 2 hours per week, per case 2.2c Anticipated duration of service (i.e. 3-4 months): 1 4 months, with option to renew service if clinically necessary 2.2d Three (3), or more, specific goals of the service (DO use bullet points): To help client and family achieve identified individualized treatment goals around: • improved function • emotional stability • establishing healthy family dynamics • ability to behave appropriately within their communities Polaris Partners providers will collaborate with client and family's team to ensure client and family have access to necessary resources for the highest chance of achieving success. Therapists will provide weekly family therapy as requested by the team. All in -person contact will be billed the same rate including therapy, team meetings, and court appearances. Other services provided include crisis follow-up availability to youth, family, and teams; coordination and planning with other involved professionals and service providers: treatment plan updates; court updates. 2.2e Three (3), or m outcomes of service: Treatment outcomes depend on many variables, primarily hinging on the ability and willingness of individual clients and families to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Although outcomes cannot be absolutely guaranteed, Polaris Partners has always and will continue to strive to meet clients and families where they are and consistently provide premium quality individualized behavioral health services with the goal being to help client and family achieve identified treatment goals toward: • improved function • mental and emotional stability • improved family dynamics • conflict resolution skills • ability to behave appropriately within their communities 2.2f Target population of the service: REV. NOV 2019 2 ATTACHMENT C - PROPOSAL TEMPLATE Youth ages 5 to 18 (sometimes younger depending on circumstance) and their families, all genders, specializing in at -risk populations. Clients dealing with mental health and substance use issues will be served. Polaris Partners providers also work with families to help create a healthy and functional family system and environment in which the client and family may thrive. 2.2g Languages service is available in (please list prc English 2.2h Medicaid eligibility — list whether the service is None Service #3 Name and if interpreter services are available for Medicaid in whole or in Intensive In -Home Therapy — Individual - Bilingual/Spanish 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, therapists will address: • individual patterns of addiction and maladaptive coping • mental health issues and community involvement • all treatment will be individualized and tailored to the specific needs and strengths of the client Evidence -based practices will be used to help client develop skills and ability to 2.3b Antici manage mood and behaviors develop intrinsic motivation to succeed improve self-control and emotion regulation develop healthy interpersonal skills en family and social bonds in addition to other specified treatment goals ncv of service per week (i.e. 4 ho 2 hours per week; per case 2.3c Anticipated duration of service (i.e. 3-4 months): 4 months, with option to renew service if clinically necessary 2.3d Three (3), or more, specific goals of the service (DO use bullet poin To help client achieve identified individualized treatment goals around: • improved function • emotional stability • ability to behave appropriately within their communities Polaris Partners providers will collaborate with client's team to ensure client has access to necessary resources for the highest chance of achieving success. Therapists will provide weekly individual therapy as requested by the team and family. All in person contact will be billed the same rate including therapy, team meetings, and court appearances. Other services provided include crisis follow-up availability to youth, family, and teams; coordination and planning with other involved professionals and service providers; treatment plan updates; court updates. 2.3e Three (3), or more, specific outcomes of service: Treatment outcomes depend on many variables, primarily hinging on the ability and willingness of clients to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Although outcomes cannot be absolutely guaranteed, Polaris Partners has always and will continue to strive to meet clients where they are and consistently provide premium quality individualized behavioral health services with the goal being to help client achieve identified treatment goals toward: • improved function • emotional stability ability to behave appropriately within their communities 2.3f Target population of the service: Polaris Partners serves youth ages 5 to 18 (sometimes younger depending on circumstance), all genders, specializing in at - risk populations. Clients dealing with mental health and substance use issues will be served. Polaris Partners providers also work with families to help create a healthy and functional family system and environment in which the client may thrive. REV. NOV 2019 3 ATTACHMENT C - PROPOSAL TEMPLATE 2.3g Languages service is available in (please list proficiency and if interpreter services are availab Spanish; Bilingual — English/Spanish 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in Dart: Service #4 Name: Intensive In -Home Therapy — Family - Bilingual/Spanish 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, therapists will address: • familial patterns of trauma and dysfunction • individual and familial patterns of addiction and maladaptive coping • family systems and roles • mental health issues and community involvement • all treatment will be individualized and tailored to the specific needs and strengths of the client and family members Evidence -based practices will be used to help client and family develop skills and ability to: • manage mood and behaviors • develop intrinsic motivation to succeed • improve self-control and emotion regulation • develop healthy interpersonal skills strengthen family and social bonds in addition to other specified treatment goals 2.4b Anticipated frequency of service per week (i.e. 4 hours/week): 2 hours per week; per case 2.4c Anticipated duration of service (i.e. 3-4 months): 4 months, with option to renew service if clinically necessary 2.4d Three (3), or more, specific goals of the service (DO use bullet points): To help client and family achieve identified individualized treatment goals around: • improved function • emotional stability • establishing healthy family dynamics • ability to behave appropriately within their communities Polaris Partners providers will collaborate with client and family's team to ensure client and family have access to necessary resources for the highest chance of achieving success. Therapists will provide weekly family therapy as requested by the team. All in -person contact will be billed the same rate including therapy, team meetings, and court appearances. Other services provided include crisis follow-up availability to youth, family, and teams; coordination and planning with other involved professionals and service providers; treatment plan updates; court updates. 2.4e Three (3). or outcomes of service: Treatment outcomes depend on many variables, primarily hinging on the ability and willingness of individual clients and families to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Although outcomes cannot be absolutely guaranteed, Polaris Partners has always and will continue to strive to meet clients and families where they are and consistently provide premium quality individualized behavioral health services with the goal being to help client and family achieve identified treatment goals toward: • improved function • mental and emotional stability • improved family dynamics • conflict resolution skills ability to behave aonroDriately within their communities 2.4f Target population of the service: Youth ages 5 to 18 (sometimes younger depending on circumstance) and their families, all genders, specializing in at -risk populations. Clients dealing with mental health and substance use issues will be served. Polaris Partners providers also REV. NOV 2019 4 ATTACHMENT C - PROPOSAL TEMPLATE work with families to help create a healthy and functional family system and environment in which the client and family may thrive. 2.4g 2.4h Medicaid None service is available in (please list proficiency and if interpreter services are ava lingual — Spanish/English •ligibility — list whether the service is eligible for Medicaid in whole or in part: Service #5 Name: 2.5a Modalities, curriculum, tools used in delive 2.5b Antici C 2.5c Antici 2.5d Three 2.5e Three 2.5f Targe 2.5g Langu freauencv of service duration of service or more, of service (DO NOT list corn week (i.e. 4 hou 3-4 months): Is of the service or more, specific outcomes of service: lation of the service: service is available in (please list proficie use bullet and if history; DO use bullet services are available): 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in Section 3 — Service Access and Transportation 3.1 Will you conduct services in your office? No 3.1a If yes, office location(s): 3.2 Will you conduct services out of the office? Yes 3.2a If yes, how many miles will you travel from your office? 32 miles 3.3 Will you transport clients to and from services? No 3.3a If yes, what is your starting point address? 300 E. Horsetooth Rd. Suite 200, Fort Collins, CO 80525 3.3b If yes, how many miles will you travel from your starting point address? SECTION 4- SERVICE RATES All rates need to include administrative work (i.e. report writing). Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly, daily, or monthly rates will be accepted for services, with the exception those listed above. Home study providers need to list their rates in 4.6. Monitored sobriety testing providers needs to list their rates in 4.7. 4.1 Service #1 Name: Intensive In -Home Therapy - Individual - English $ Amount Unit Type 4.1a In -Office rate: per 4.1b Out -of -office rate: $180 per hour Catchment area in miles: 32 miles 4.1c FTM, TDM, Prof. Staffing: $180 per hour 4.1d No show: $60 per Round trip 4.1e Mileage rate after catchment: .56 per Mile 4.1f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month REV. NOV 2019 5 ATTACHMENT C - PROPOSAL TEMPLATE 4.2 Service #2 Name Intensive In -Home Therapy — Family - English $ Amount unit uType 4.2a In -Office Rate: 4.2b Out -of -Office Rate: 4.2c FTM, TDM, Prof. Staffing: 4.2d No show: 4.2e Mileage rate after catchment: $60 .56 per per per per per m y hour hour Round Trip Mile Catchment area in miles: 32 I miles 4.2f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.3 Service #3 Name: Intensive In -Home Therapy — Individual - Bilingual/Spanish 4.3a In -Office Rate: 4.3b Out -of -Office Rate: 4.3c FTM, TDM, Prof. Staffing: 4.3d No show: 4.3e Mileage rate after catchment: $ Amount per per per per per $240 $240 $60 .56 Unit Type hour hour Round Trip Mile Catchment area in miles: 32 miles 4.3f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.4 Service #4 Name: Intensive In -Home Therapy — Family - Bilingual/Spanish $ Amount unit T e Type 4.4a In -Office Rate: 4.4b Out -of -Office Rate: 4.4c FTM, TDM, Prof. Staffing: 4.4d No show: 4.4e Mileage rate after catchment: $60 56 per per per per per hour hour Round Trip Mile Catchment area in miles: 32 miles 4.4f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month 4.5 Service #5 Name: $ Amount Unit Type 4.5a 4.5b 4.5c 4.5d 4.5e 4.6 Home Stu In -Office Rate: Out -of -Office Rate: FTM, TDM, Prof. Staffing: No show: Mileage rate after catchment: per per per per per Mile Catchment area in miles: miles 4.5f If the rate(s) listed above are a monthly package, complete the boxes below. No. of Face-to-face hours: per month No. of admin/case management hours: per month No. of travel hours per month TOTAL HOURS: per month Providers — List vour rates in the box below. REV. NOV 2019 6 ATTACHMENT C - PROPOSAL TEMPLATE 4.7 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: REV. NOV 2019 nscyawci SERVICE TYPE: Program Area; Home -Based Intervention; Service Type: Intensive In -Home Therapy - Individual ATTACHMENT rvlces.) Didd -muaat list nII��Iir �Iq taffwho wry manage tl L LNII A 1 written on w-9: /or. aminister the proposed 5arvicel Ogne Saff Data Sheet per proposed service. Bidder should not combine dlarl5 partners Chun a and Lonsu tin APPLICABLE STAFFMEMBER OR CONTRACTOR INFORMATION - - - sopERVISORINFORMATtOM No. LegalUrt Name Presious Legal Lose Name (Ifapplhable) Legal First Namt WorNg Work Email Education Level: Degree Fans Gcenwre( Credentials DO RAN -Lii appllrablel Lazf Name First Name ;= WOrkX - '" s Work 3 Dotson Damond 866285-2929 damond.dotson(d o spartnerscc.com PhD Marriage and Family Counseling LMFT MFT.0000526 lessen Thadeus 866285-2929 thade s'essenNtoolarisoartnerscccom 2 lessen Thadeus 866-285-2929 thadeus.-essen olaris artnerscc.com MA Clinical Mental Health Counseling LPC LPC.0003535 Dotson Damond 866285-2929 damond.dotson olaris artnerscc.mm 3 Gerber Victoria 866-285-2929 victoria.eerber(vloolarisoartnerscccom MA Clinical Mental Health Counseling LPC, CACTI LPC.001410T, AC8.00083]] Dotson Demand 866-285-2929 damond.dotsan(doolarisoartnerscc.mm 4 Wilson Eric 866-285-2929 ericwilsonpoolarisoannerscc.core ME Counseling and Career Developmen LPC LPC.0015520 Dotson Damond 866-285-2929 damond.dotson olaris annex cc.mm 5 Lucas Rachel 866-285-2929 rachel.lucas@polarispartnerscc.com MA Clinical Mental Health Counseling LPC CACII LPC.0013958, ACB.0008341 Dotson Damond 866-285-2929 damonddotson(doolarisoartnersccmm 6 Andresen Glenda 866-285-2929 Glendaandresen(mpolarisoartnerscccom MA Marriage and Family Counseling LMFT MFT.0000632 Dotson Damond 866-285-2929 damond.dotsoneoolarlsoartnerscc.com 7 Ryan Emilie 866-285-2929 emilie.r an@polaris artnerscccom MA Clinical Mental Health Counseling LPC LPC.0013811 Dotson Damond 866-285-2929 damond.dotson olaris artnerscc.com B Simons Sheila 866-285-2929 sheilasimons/apolarispartnerscccom MA Professional Counseling LPCC LPCC.0016767 Dotson Damond 866-285-2929 damond.dotson faoolarisoartnerscccom 9 20 11 12 13 14 15 16 1] 38 19 20 21 22 23 24 25 26 27 28 SERVICE TYPE: Program Area:Home-Based Intervention; Service Type: Intensive In -Home Therapy -I AL (Spanish) 8pgpER LEG EN TV NAMc (AS en o W-9): Iaris P;rtpers ounseling a d Copsulting, LLC APPLICABLE -STAFF MEMBER OR CONLRACTOR INFORMATION nvt i. rS=3 _ LNioR6gh No. Legal Last Name PreviO e; legal Lest Name If applicable ( ) Legal First Name Workp' Work Email _ Education Level Degreefocus Depplicable) 6censure/ Oederdiels DORA# (Ito . r i = kph 4r ` to ` " "" 4' ey 4 a �� ,.*�r SF(�z' "" a • 1 Wilson Eric 866-285-2929 eric.wilson@polarisoartnerscccom ME Counseling and Career Development LPC LPC.0015520 Dotson Damond 866-285-2929 damond.dotson(doolarisoai 2 3 4 5 6 7 8 9 10 11 12 13 14 SS 16 17 18 19 20 21 22 23 24 25 26 27 28 POLAPAR-01 HHASTIN N Ac®RO" DATE (MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 3/30/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer riqhts to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Howard Insurance Agency, Inc. PHONE 6900 Wisconsin Ave Fifth Floor (A/C, No, Ext): (301) 652-2500 AIChevy Chase, MD 20815 ADDRS: IN E O@ FO H®WAR® INSURER A: INSURED INSURERB: : Polaris Partners Counseling & Counseling LLC INSURER C: PO Box 273061 INSURER O: Fort Collins, CO 80527 INSURER E: COVERAGES RANCE.COM REVISION NUMBER: 652-2530 37540 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP M' MM/DDYY LIMITS A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000'000 CLAIMS -MADE ❑ OCCUR 42SBAUH0128 12/5/2019 12/5/2020 DAMAGE TO RENTED PREMISES (Ea occurrence 1,000,000 $ MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2'000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY PRO- JECT ❑ LOC OTHER: $ A AUTOMOBILE LIABILITY EOa accident) MBINED SINGLE LIMIT $ 2,000,000 ANY AUTO 42SBAUH0128 12/5/2019 12/5/2020 BODILY INJURY Per erson $ BODILY INJURY (Per accident) $ OWNED SCHEDULED AUTOS ONLY AUTOS PROPERTY DAMAGE (Per accident) $ X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY YIN PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER ❑ EXCLUDED? (Mandatory in NH) NIA 42WECCR9690 12/5/2019 12/5/2020 X PER STATUTE 0TH - ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1,000'000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below B Data Breach/Cyber V1756D190601 12/5/2019 12/5/2020 Limit 1,000,000 A Bus. Personal Prop. 42SBAUH0128 12/5/2019 12/5/2020 REPLACEMENT COST 25,100 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This certificate names Weld County, the Board of County Commissioners of Weld County and it Officers/Employees as additional Insureds with respect to General Liability and Commercial Auto Liability where required by written contract. TION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Weld County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1150 'O' Street Greeley, CO 80631 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLARISPARTNERS CONSULTING November 1, 2019 The attached professional liability insurance policy covers all employees of Polaris Partners Counseling and Consulting LLC. The following staff members are employed by Polaris Partners Counseling and are covered by our professional liability policy with HPSO: Damond Dotson Thadeus Jessen Victoria Gerber Eric Wilson Rachel Lucas Glenda Andresen Emilie Ryan Kathryn Romeo Alastair Johnson Sheila Simons If you have additional questions, please contact me. Damond Dotson, Ph.D.. LMFT Owner 970-576-1717 300 E. Horsetooth Rd. Suite 200, Fort Collins CO 80525 866-285-2929 info@poladspartnerscc.com HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP unSOO Certificate of ,fu5urance 1 11 V Print Date: 10/16/19 OCCURRENCE PROFESSIONAL LIABILITY POLICY FORM 020200002 018098 I 970 I HPG I 0615479691 Named Insured Polaris Partners, LLC 300 E Horsetooth Rd Ste 200 Fort Collins, CO 80525-3154 Medical Specialty Code Licensed Professional Counselor Firm 80723 Excludes Cosmetic Procedures Professional Liabili Policy Period: From 11/01/19 to 11/01/20 at 12:01 AM Standard Time Proaram Administered bv: Healthcare Providers Service Organization 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034-3278 1-888-288-3534 www.hpso.com Insurance is provided by: American Casualty Company of Reading, Pennsylvania 333 South Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $5,000,000 aggregate Your professional liability limits shown above include the following: • Good Samaritan Liability • Malplacement Liability • Personal Injury Liability • Sexual Misconduct included in the PL Limit shown above subject to $25,000 aggregate sublimit Coveraae Extensions License Protection $25,000 per proceeding $25,000 aggregate Defendant Expense Benefit $1,000 per day limit $25,000 aggregate Deposition Representation $10,000 per deposition $10,000 aggregate Assault $25,000 per incident $25,000 aggregate Includes Workplace Violence Counseling Medical Payments $25,000 per person $100,000 aggregate First Aid $10,000 per incident $10,000 aggregate Damage to Property of Others $10,000 per incident $10,000 aggregate Enterprise Privacy Protection - Claims Made $25,000 per incident $25,000 aggregate Retroactive Date: 11/01/15 - Defense inside limits Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire and Water Legal Liability Included in the PL limit above subject to $150,000 aggregate sublimit Total: $4,643.00 Policy Forms & Endorsements (Please see attached list for a general description of many common policy forms and endorsements.) G -121500-D G -121501-C G -121503-C G -145184-A G -147292-A CNA81753 CNA81758 GSL13424 GSL13425 GSL15564 GSL15565 GSL17101 CNA80052 CNA82011 G -123846-005 G -123828-B CNA79516 G -121486-B CNA79575 Chairman of the Secretary Keep this document in a safe place. It and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in full. In order to activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance. Form #: G -141241-B Master Policy #: 188711433 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide the following services under this Agreement, as referred by the Department. a. Intensive In -Home Individual and Family Therapy: Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, Contractor will address individual and familial patterns of addiction, mental health issues and community involvement. All treatment will be individualized and tailored to the specific needs and strengths of the client and/or family. Evidence -based practices will be used to help client and family develop skills and ability to manage emotions, develop healthy interpersonal skills, and strengthen family and social bonds in addition to other specific treatment goals. Capacity to Provide Services: Two (2) hours per week, per case. Anticipated duration of services is four (4) months. ii. Goals of Service: To help client and/or family achieve identified individualized treatment goals toward improved function, emotional stability, and ability to behave appropriately in their communities. iii. Outcomes of Service: Treatmert outcomes will depend on many variables, primarily hinging on the ability and willingness of clients to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Contractor will: 1. Strive to meet clients where they are. 2. Consistently provider premium quality individualized behavioral health services. iv. Target Population: 1. Youth, ages five (5) to 18 years of age 2. All genders 3. Specializing in at -risk populations v. Service Access: 1. Contractor will travel up to 32 miles from 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. vi. Language: English and Spanish. 2. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 3. 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 Supervisor (hainleid@weldgov.com, 970-400-6210). 4. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. 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 Supervisor (hainleid@weldgov.com, 970-400-6210). 1 5. 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 Supervisor (hainlejd@weldgov.com) immediately via email, to discuss service continuation. 6. 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. 7. 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. 8. 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. 9. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 10. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as the meeting is at least one hour in length, the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. 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. 11. Contractor will notify the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400-6210) 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. 2 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, 2021. 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 Intensive In -Home Therapy — Individual or Family - English: $180.00/Hour (Out -of -Office) $180.00/Hour (FTM, TDM, Prof. Staffing) $60.00/Round Trip (No show) $ .56/Mile (Mileage) — For distance exceeding thirty (30) miles from practitioner's office located at 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. Intensive In -Home Therapy — Individual or Family — Bilingual/Spanish: $240.00/Hour (Out -of -Office) $240.00/Hour (FTM, TDM, Prof. Staffing) $60.00/Round Trip (No show) $ .56/Mile (Mileage) — For distance exceeding thirty (30) miles from practitioner's office located at 300 Horsetooth Road, Suite 200, Fort Collins, CO 80525. 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. New Contract Request Entity Information Entity Namet Ent 1Li POLARIS PARTNERS LLC §00036707 Contract :NLIflet POLARIS PARTNERS (CHILD PROTECTION AGREEMENT FOR SERVICES) Contract Status CTS REVIEW ❑ New Entity? Contract I 3540 Contract Lead * CULLI₹TA Contract Lead Email cu.LintaaicawaidLcaus Parent Contract ID Requires Board Approval YES Department Project # Q)fflyfl Description Descriptiont CONSENT. BID NO. 2000037. NEW AGREEMENT FOR SERVICES. TERM: JUNE 1, 2020 THROUGH MAY 31, 2021. FURNDING: CORE/OTNER Contract Desiption 2 Contract Type . AGREEMENT Aanount* ;0.00 Renewable YES Automatic Renewal Department HUMAN SERVICES Department Email CM- HunanServices@weidgov.com Department Head Email CM-HurnanServiAces- DeptHeadi, weldgov.corn County Attorney Grant GENERAL COUNTY ATTORNEY EMAIL IGA County Attorney Email CM- COtli TYATTOR:NEY @VELD GOV. COM if this is a renewal enter previous Contract ID }iRttIt 7 ttni ii.nu Iii Requested C Agenda Due Date Date* 04/10}2020 04/22/2020 Will a work session with 80CC be required?* NO Does Contract require Purchasing Dept. to be included? Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Review: Date 0 If01/2021 Renewal Date 06/01/2021 Termination Notice Period Committed Delivery Date Expiration Date Contact Information Department Head JAMIE UL ICH DH Approved Date 04'2112020 Tyler Ref AG 042720 da Dale 04127/2020 Originator SNYDERKL Submit Contact Phone 2 Leqa Counsel GABE KALOUSEK Legal Counsel Approved Date 04/222020 Hello