HomeMy WebLinkAbout20222611.tiffRESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN - DOMINIC JOSEPH SMITH, DBA OUR VILLAGE COUNSELING, LLC
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Child Protection Agreement for Services
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Human Services, and
Dominic Joseph Smith, dba Our Village Counseling, LLC, commencing July 1, 2022, and ending
May 31, 2023, with further terms and conditions being as stated in said agreement, and
WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the Child Protection Agreement for Services between the County of
Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on
behalf of the Department of Human Services, and Dominic Joseph Smith, dba Our Village
Counseling, LLC, be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 14th day of September, A.D., 2022, nunc pro tunc July 1, 2022.
BOARD OF COUNTY COMMISSIONERS
WELJD COUNTY, COLORADO
ATTEST: ;(1
Weld County Clerk to the Board
County At.•*''ey
Date of signature: 9/141/2-2.
cdtt K. James, Chair
teve Moreno
Lori Saine
cc : HS D
o/y /22
2022-2611
HR0094
Con-VQCtI l)1,(DZ9c1
PRIVILEGED AND CONFIDENTIAL
MEMORANDUM
DATE: September 6, 2022
TO: Board of County Commissioners — Pass -Around
FR: Jamie Ulrich, Director, Human Services
RE: Child Protection Agreement with Dominic Joseph
Smith dba Our Village Counseling, 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 Child Protection Agreement with Dominic
Joseph Smith dba Our Village Counseling, LLC. The Department is requesting to enter into a
Child Protection Agreement for Mental Health Services. The term of the Agreement shall be
from June 1, 2022 through May 31, 2023.
Fees for Services
Mental Ileallh ticr%ices
Rate
Unit Type
Service Name
$100.00
Hour
In-Office/Video
$150.00
Hour
Family Team Meeting (FTM), Team Decision Making (TDM) Meeting,
Professional Staffing
Rate
$125.00
licunificatinn I hura ,
Unit Type Service Name
Hour
In-OfficeNideo
In- Family Team Meeting (FTM), Team Decision Making (TDM) Meeting,
Professional Staffing
$125.00
Hour
1 hv r:ionto l'i itation
Rate
Unit Type
Service Nome
$100.00
Hour
In-Office/Video
$100.00
Hour
Family Team Meeting (FTM), Team Decision Making (TDM) Meeting,
Professional Staffing
Pass -Around Memorandum; September 6, 2022 - CMS ID 6294
Pace 1
2022-2611
PRIVILEGED AND CONFIDENTIAL
I do not recommend a Work Session. I recommend approval of this Agreement and authorize the
Chair to sign.
A rove Schedule
Recommendation Work Session Other/Comments:
Peary L. Buck
Mike Freeman, Pro-Tem
Scott K. James, Chair
Steve Moreno
Lori Saine
,414
x
Pass -Around Memorandum; September 6, 2022 — CMS ID 6294 Page 2
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND DOMINIC JOSEPH SMITH DBA OUR VILLAGE COUNSELING, LLC
, i-M1
This Agreement, made and entered into the ]_1_ day of . p4,mbez- 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 Dominic Joseph Smith dba Our Village Counseling, hereinafter referred to as
the "Contractor".
The parties to this Agreement understand and agree that the provisions of this Agreement specifically include
the following documents: Exhibit A, Scope of Services, Exhibit B, Rate Schedule, Exhibit C, Weld County's Request
for Proposal, and Exhibit D, Contractor's Response to Request for Proposal. Exhibit A, B, and D are attached hereto
and incorporated herein by this reference. Exhibit C is Weld County's Request for Proposal Number B2200040 which
is incorporated into this agreement by reference and will be provided upon request to the Department.
WITNESSETH
WHEREAS, required approval, clearance, and coordination have been accomplished from and with
appropriate agencies; and
WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to
the Department for Mental Health Services.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows:
1. Term
This agreement shall become effective on July 1, 2022, upon proper execution of this Agreement and shall
expire May 31, 2023, unless sooner terminated as provided herein.
2. Scope of Services
Services shall be provided by the Contractor to any person(s) eligible for services in compliance with
Exhibit A Scope of Services, and Exhibit D, Contractor's Response to Request for Proposal.
3. Referrals, Billing and Tracking
a. Contractor understands and will comply with all aspects of the referral authorization, billing and
tracking requirements as set forth by the Department. Failure to comply with all aspects may result in
a forfeiture of payment.
b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e-
mail address prior to the start of this Agreement. Contractor acknowledges that services are not
authorized until the Contractor has received an authorized referral form from the Department.
Contractor further acknowledges that services provided prior to the authorized start date or outside the
scope of services on the referral form will not be eligible for reimbursement.
Contractor acknowledges that any and all modifications to an existing referral must be approved
through the Quality Assurance Team (HS-CWOualitvAssurance(&,weldgov.com). No other
Department staff or other party to the case may authorize services or modifications to services.
c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation
by the 7t" of the month, following the month of service, utilizing billing forms required by the
Department. Requests for Reimbursement Forms received after 45 days from the date of service may
result in delay or forfeiture of payment. Consistent failure to meet 45 -day deadline may result in
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termination of the Agreement.
d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of
service, for each client receiving ongoing services. Monthly reports will be submitted through the
Department's online reporting system, unless otherwise directed or agreed to by the Department.
Monthly reports for ongoing services must include the following information, entered in the
"Narrative" box for each date of service:
a. Date and time(s) of service (i.e. two hours or 2-4pm)
b. Location of where the service took place (i.e. clinician's office, client's home, in the
community.)
c. Clinician/therapist name
d. Clients participating
e. What interventions were used, recommendations and/or goals discussed
f. Any and all safety concerns
One-time services will be verified through receipt of the completed product (ex. psychological
evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will
be the test result. A completed home study may be a full, partial or denied study, as determined by the
Department.
Contractor will document in detail any and all observed or verbalized concerns regarding any child
whom the Contractor is working with under the Agreement. Areas of concern may include, but are not
limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be
reported immediately to the caseworker AND on the required monthly report.
4. Payment
a. The Department and the Contractor agree that all benefits from private insurance and/or other
funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's
Compensation must be exhausted before Core Services or other Department funds can be accessed for
services. Exceptions to this Paragraph may include, if approved by the Department, the following:
i. The service being provided by the contractor is not a Medicaid eligible service;
ii. The service is not deemed medically necessary;
iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider
or service be used;
iv. A Medicaid provider is not available to provide the needed service;
v. Medicaid is exhausted for the needed service; or
vi. Medicaid denied service.
vii. The client is not eligible for Medicaid.
b. Payment shall be made in accordance with Exhibit A, Scope of Services , Exhibit B, Rate
Schedule, Exhibit C, Weld County's Request for Proposal, and Exhibit D, Contractor's Response to
Request for Proposal., attached hereto and incorporated herein by reference, so long as services are
rendered satisfactorily and in accordance with the Agreement.
c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent
upon, the continuing availability of said funds for the purposes hereof.
d. The Department may withhold reimbursement if Contractor has failed to comply with any part of
the Agreement, including the Financial Management requirements, program objectives, contractual
terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal
such circumstance in writing to the Director of Human Services. The decision of the Director of
Human Services shall be final.
5. Financial Management
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At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall
comply with the administrative requirements, cost principles and other requirements set forth in the
Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds
expended under this Agreement must conform to the Single Audit Act of 1984 and OMB Circular A-133.
6. Payment Method
Unless otherwise provided in Exhibit A, Scope of Services, Exhibit B, Rate Schedule, and Exhibit D,
Contractor's Proposal:
a. If services are funded through Core Services, Contractor agrees to accept reimbursement through
ACH direct deposit one time per month.
b. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor
agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be
provided by the Department, with a voided check. Failure to complete and submit this form and
voided check in a timely and accurate manner may result in a delay of payment.
c. Contractor agrees to accept payment through county warrant when funding source does not allow
for direct deposit.
7. Compliance with Applicable Laws
a. At all times during the performance of this Agreement, Contractor will strictly adhere to all
applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or
guidelines issued pursuant thereto. This includes protection of the confidentiality of all
applicant/recipient records, papers, documents, tapes and any other materials that have been or may
hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws
and regulations, including, but not limited to the following:
- Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil
Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. sec. and its implementing regulation, 45
C.F.R. Part 80 et. se�C .; 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. m, 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
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Rehabilitation Act of 1973, as amended, cited above. If necessary, Contractor and the
Department will resist in judicial proceedings any efforts to obtain access to client records
except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires
that affirmative steps be taken to assure that small and minority businesses are utilized, when
possible, as sources of supplies, equipment, construction and services. This assurance is
given in consideration of and for the purpose of obtaining any all Federal and/or State
financial assistance.
- Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record
checks for all employees, contractors and sub -contractors.
b. Contractor is further charged with the knowledge that any person who feels that s/he has been
discriminated against has the right to file a complaint either with the Colorado Department of Human
Services or with the United States Department of Health and Human Services, Office for Civil Rights.
c. Contractor assures that it will fully comply with all other applicable Federal and State laws which
may govern the ability of the Department to comply with the relevant funding requirements.
Contractor understands the source of funds to be accessed under the Agreement is determined by the
Department.
d. Contractor assures and certifies that it and its principals:
- Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transaction by a Federal or State department or agency;
and
- have not, within a three-year period preceding this Agreement, been convicted of or had a
civil judgment rendered against them for commission of fraud or criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State or
Local) transaction or contract under public transaction; violation of federal or state antitrust
statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen property; and
- are not presently indicted for or otherwise criminally or civilly charged by a government
entity (federal, state or local) with commission of any of the offenses enumerated in this
certification; and
- have not, within a three-year period preceding this Agreement, had one or more public
transactions (federal, state, or local) terminated for cause or default.
e. Public Contracts for Services C.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that
it does not knowingly employ or contract with an illegal alien who will perform work under this
contract. Contractor will confirm the employment eligibility of all employees who are newly hired for
employment in the United States to perform work under this Agreement, through participation in the E -
Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5-
102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work
under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor
that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under
this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to
undertake pre -employment screening or job applicants while this Agreement is being performed. If
Contractor obtains actual knowledge that a subcontractor performing work under the public contract for
services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor
and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is
employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does
not stop employing or contracting with the illegal alien within three (3) days of receiving
notice. Contractor shall not terminate the contract if within three days the subcontractor provides
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information to establish that the subcontractor has not knowingly employed or contracted with an illegal
alien. shall comply with reasonable requests made in the course of an investigation, undertaken pursuant
to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and Employment. If Contractor
participates in the State of Colorado program, Contractor shall, within twenty days after hiring a new
employee to perform work under the contract, affirm that Contractor has examined the legal work status
of such employee, retained file copies of the documents, and not altered or falsified the identification
documents for such employees. Contractor shall deliver to the Department, a written notarized
affirmation that it has examined the legal work status of such employee and shall comply with all of the
other requirements of the State of Colorado program. If Contractor fails to comply with any requirement
of this provision or of C.R.S. §8-17.5-101 et seq., the Department, may terminate this Agreement for
breach, and if so terminated, Contractor shall be liable for actual and consequential damages.
f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if
Contractor receives federal or state funds under the contract, Contractor must confirm that any
individual natural person eighteen (18) years of age or older is lawfully present in the United States
pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the
contract. If Contractor operates as a sole proprietor, it hereby swears or affirms under penalty of
perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the United States
pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24-
76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. § 24-76.5-
103 prior to the effective date of the contract.
8. Compliance with Child and Family Services Review
The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas;
Safety, Permanency and Well Being of families. For each outcome, data and performance indicators
measure each state's performance according to national standards and monitor progress over time.
Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance
services to families.
Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well
Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under
this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under
the Child and Family Services Review (CFSR), and will address the aforementioned three areas when
completing monthly reports as required by Paragraph 3(d) of this Agreement.
9. Insurance Requirements
Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld
County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent
acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while
performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless
Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents.
Contractor shall provide the liability insurances (including professional liability insurances where
necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged in
the performance of this Agreement which are required under Weld County's Request for Proposal, and
required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the
acceptable evidence that such coverage is in effect prior to execution of this Agreement.
At a minimum, Contractor shall procure, either personally or through its employer as applicable to the
Contractor's business, at its own expense, and maintain for the duration of the work, insurance coverage
listed in this agreement. The Board of County Commissioners of Weld County and its Officers/Employees
shall be named as additional insured.
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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.
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v.For all general liability, excess/umbrella liability, liquor liability, pollution liability and
professional liability policies, if the policy is a claims -made policy, the retroactive date
must be on or before the contract date or the first date when any goods or services were
provided to the Department, whichever is earlier.
c. Contractors shall secure and deliver to County's Risk Administrator ("Administrator") at
or before the time of execution of this Agreement, and shall keep in force at all times during the
term of the Agreement as the same may be extended as herein provided, a commercial general
liability insurance policy, including public liability and property damage, in form and company
acceptable to and approved by said Administrator, covering all operations hereunder set forth in the
related Bid or Request for Proposal.
d. Proof of Insurance: Contractor shall provide a copy of this information to its insurance
agent or broker and shall have its agent or broker provide proof of Contractor's required insurance.
The Department reserves the right to require Contractor to provide a certificate of insurance, a
policy, or other proof of insurance as required by the County's Risk Administrator in his sole
discretion.
e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal
liability, liquor liability, and inland marine, Contractor's insurer shall name County as an additional
insured.
f. Waiver of Subrogation: For all coverages, Contractor's insurer shall waive subrogation
rights against County.
g. Subcontractors: All subcontractors, independent contractors, sub -vendors, suppliers or
other entities providing goods or services required by this Agreement shall be subject to all of the
requirements herein and shall procure and maintain the same coverages required of Contractor.
Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers or
other entities as insureds under its policies or shall ensure that all subcontractors maintain the
required coverages. Contractor agrees to provide proof of insurance for all such subcontractors,
independent contractors, sub -vendors, suppliers or other entities upon request by the Department.
A provider of Professional Services shall provide the following
coverage:
Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and
$2,000,000 aggregate limit for all claims.
10. Certification
Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary
licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by
this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor
prior to the start of my Agreement.
11. Training
Contractor may be required to attend training at the request of the Department specific to services provided
under this Agreement. The Department will not compensate the Contractor for said training in the form of
registration fees, time spent traveling to and from training, attending the training or any other associated
costs unless otherwise agreed to by the Department.
12. Subpoenas
Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the
7
Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours.
For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the
Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact
the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be
personally served.
13. Monitoring and Evaluation
Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement
shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation
shall be provided to the Board of Weld County Commissioners, the Department and the Contractor.
Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service
delivery, service quality, documentation, and invoicing during referral period and after services have
concluded. The Contractor will require clients sign releases of information. Contractor understands that
the Department will not reimburse for services rendered to Department clients until releases of information
are obtained.
Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to
monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring
agency may, if in its sole discretion deems necessary or appropriate, have access to any program data,
special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for
purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere
with the work conducted under this Agreement.
14. Modification of Agreement
All modifications to this Agreement shall be in writing and signed by both parties.
15. Remedies
The Director of Human Services or designee may exercise the following remedial actions should s/he find
the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure
to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the
Contractor. These remedial actions are as follows:
- Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed.
- Deny payment or recover reimbursement for those services or deliverables, which have
not been performed and which due to circumstances caused by the Contractor cannot be
performed or if performed would be of no value to the Department. Denial of the amount of
payment shall be reasonably related to the amount of work or deliverables lost to the
Department.
- Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall
be recovered from Contractor by deduction from subsequent payments under this Agreement
or other agreements between the Department and Contractor, or by the Department as a debt
due to the Department or otherwise as provided by law.
16. Representatives
For the purpose of this Agreement, the individuals identified below are hereby designated representatives
of the respective parties. Either party may from time to time designate in writing a new or substitute
representative(s).
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For Department: For Contractor:
Heather Walker, Child Welfare Division Head Dominic Smith, LPC, RPT 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) 400-6510
18. Litigation
For Contractor:
Dominic Smith, LPC, RPT Owner
2627 Redwing Road, Suite 235
Fort Collins, Colorado 80526
(970) 658-7121
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• sea•, as applicable now or hereafter amended.
22. Partial Invalidity of Agreement
If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held
or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The
parties hereto declare that they would have entered into this Agreement and each and every section,
subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more
9
sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or
invalid.
23. Improprieties/Conflict of Interest
No officer, member or employee of Weld County and no member of their governing bodies shall have any
pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof.
The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department
when the Contractor also maintains a relationship with a third party and the two relationships are in
opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor
to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the
two relationships are in opposition. During the term of the Agreement, Contractor shall not enter into any
third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an
existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full
disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to
promptly submit a disclosure statement required by this paragraph shall constitute grounds for the
Department's termination, for cause, of its Agreement with the Contractor.
A conflict of interest or appearance of a conflict of interest may also apply to personal relationships
between providers and clients. If a provider has a personal relationship with a client to whom the
Contractor may provide services for, the Contractor must disclose that relationship to the Department.
Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of
Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with the awarding of any Federal contract, the making of any Federal grant, the making of any
Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of an Federal contract, loan, grant, or cooperative agreement.
24. Storage, Availability and Retention of Records
Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during
business hours, have access to inspect and copy records, and shall be allowed to monitor and review
through on -site visits, all activities related to this Agreement, supported with funds under this Agreement,
to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and
evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The
results of the monitoring and evaluation activities shall be provided to the appropriate and interested
parties.
All such records, documents, communications, and other materials created pursuant or related to this
Agreement shall be maintained by the Contractor in a central location and shall be made available to the
Department upon its request, for a period of seven (7) years from the date of final payment under this
Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or
until an audit has been completed with the following qualifications: If an audit by or on behalf of the
Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or
if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the
resolution of the audit finding.
25. Confidentiality of Records
Contractor shall protect the confidentiality of all applicant records and other materials that are maintained
in accordance with this Agreement except for purposes directly connected with the administration of Child
Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall
be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in
accordance with the Contractor's written policy governing access to, duplication and dissemination of, all
10
such information, in any form, including social networks. Contractor shall advise its employees, agents,
and subcontractor, if any, that they are subject to these confidentiality requirements.
Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written
explanation of these confidentiality requirements before access to confidential data is permitted.
Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality
agreement and shall provide a copy of such agreement to the Department, if requested.
26. Proprietary Information
Proprietary information for the purposes of this Agreement is information relating to a party's research,
development, trade secrets, business affairs, internal operations and management procedures and those of
its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties,
(2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use
or disclose directly or indirectly without prior written authorization any proprietary information concerning
the other party obtained as a result of this Agreement. Any proprietary information removed from the
Department's site by the Contractor in the course of providing services under this Agreement will be
accorded at least the same precautions as are employed by the Contractor for similar information in the
course of its own business.
27. Independence of Contractor: Not an Employee of Weld County
Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees
will not become employees of County, nor entitled to any employee benefits from County as a result of the
execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor.
Contractor shall be solely responsible for its acts and those of its agents and employees for all acts
performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to
unemployment insurance or workers' compensation benefits through County and County shall not
pay for or otherwise provide such coverage for Contractor or any of its agents or employees.
Unemployment insurance benefits will be available to Contractor and its employees and agents only
if such coverage is made available by Contractor or a third party. Contractor shall pay when due all
applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant
to this Agreement. Contractor shall not have authorization, express or implied, to bind County to any
agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have
the following responsibilities with regard to workers' compensation and unemployment compensation
insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation
insurance in the amounts required by law, and as set forth in Exhibit C, provide proof thereof when
requested to do so by County.
28. Entire Agreement
This Agreement, together with all attachments hereto, constitutes the entire understanding between the
parties with respect to the subject matter hereof, and may not be changed or modified except as state in
Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal
representatives, and assigns. The Contractor and the Department may not assign any of its rights or
obligations hereunder without the prior consent of both parties.
29. Agreement Nonexclusive
This Agreement does not guarantee any work nor does it create an exclusive agreement for services.
30. Warranty
The Contractor warrants that services performed under this Agreement will be performed in a manner
consistent with the professional standards governing such services and the provisions of this Agreement. The
Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence
11
and judgment provided by highly competent individuals and entities that perform services of a similar nature
to those described in this Agreement including Exhibits A, B, C, and D.
31. Acceptance of Services Not a Waiver
Upon completion of the work, the Contractor shall submit to the Department originals of all tests and
results, reports, and other similar items, generated during completion of this work. Acceptance by the
Department of reports and incidental material(s) furnished under this Agreement shall not in any way
relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any
action by the Department hereunder constitute or be construed to be a waiver by the Department of any
breach of covenant or default which may then exist on the part of the Contractor, and the Department's
action or inaction when any such breach or default shall exist shall not impair or prejudice any right or
remedy available to the Department with respect to such breach or default; and no assent, expressed or
implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be
deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any
services performed under this Agreement shall not be construed as a waiver of any of the Department's
rights under this Agreement or under the law generally.
32. Employee Financial Interest/Conflict of Interest. C.R.S. $$24-18-201 et seq. and 524-50-507
The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any
personal or beneficial interest whatsoever in the service or property which is the subject matter of this
Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would
in any manner or degree with the performance of the Contractor's services and the Contractor, shall not
employ any person having such known interests. During the term of this Agreement, the Contractor shall
not engage in any in any business or personal activities or practices or maintain any relationships which
actually conflicts with or in any way appear to conflict with the full performance of its obligations under
this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the
Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor
nor any member of the Contractor's family shall serve on a County Board, committee or hold any such
position which either by rule, practice or action nominates, recommends, supervises Contractor's
operations, or authorizes funding to the Contractor.
33. Board of County Commissioners of Weld County Approval
This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld
County, Colorado.
34. Choice of Law/Jurisdiction
Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation,
execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference
which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute
between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction
to resolve said dispute.
35. Subcontractors
Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular
reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the
completion of this project without the Department's prior written consent, which may be withheld in the
Department's sole discretion.
36. Attorney's Fees/Legal Costs
12
In the event of a dispute between the Department and Contractor, concerning this Agreement, the parties
agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or
on its own behalf.
37. Ownership
All work and information obtained by Contractor under this Agreement or individual work order shall
become or remain (as applicable), the property of the Department. In addition, all reports, documents, data,
plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all
reports, test results and all other tangible materials obtained and/or produced in connection with the
performance of this Agreement, whether or not such materials are in completed form, shall at all times be
considered the property of the Department. Contractor shall not make use of such material for purposes other
than in connection with this Agreement without prior written approval of the Department.
38. Interruptions
Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or
otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its
reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or
Governmental actions.
39. Severability
If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of
competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent
that this Agreement is then capable of execution within the original intent of the parties.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and
year first above written.
COUNTY:
ATTEST: W... tom• jC''°"14;ii'
Weld Cou Clerk to the Board
13
BOARD OF COUNTY COMMISSIONERS
WELD CJ3UNTY, COLORADO
Scott K. James, Chair
SEP 14 2022
CONTRACTOR:
Dominic Joseph Smith dba
Our Village Counseling, LLC
2627 Redwing Road, Suite 235
Fort Collins, Colorado 80526
(970) 658-7121
Qfr
By: Dominic Smith :Aug 31, 202216:36 MDT)
Date:
Dominic Smith, LPC, RPT Owner
Aug 31, 2022
c20m —o2/ /1
EXHIBIT A
SCOPE OF SERVICES
Contractor will provide Mental Health Services, as referred by the Department.
1. Mental Health Services
a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services
under this agreement:
i. Child Parent Relational Therapy (CPRT)
ii. Play therapy
iii. Cognitive Behavior Therapy (CBT)
iv. Dialectical Behavior Therapy (DBT)
v. Creative arts therapy
vi. Trauma informed treatment
vii. Psychoeducational training for parents and child regarding development
b. Anticipated Frequency of Services:
i. One (1) to two (2) times per week for a total of one (1) to four (4) hours.
c. Anticipated Duration of Services:
i. Four (4) to six (6) months, depending on the client's need.
d. Goals of Services:
i. Greater integration to self.
ii. Greater coherence with family system.
iii. Increase of desired behaviors, showing improvement in social and emotional well-being.
e. Outcomes of Services:
i. Client will gain a greater integration to self.
ii. Client will gain a greater coherence with family system.
iii. Client will have an increase of desired behaviors, showing improvement in social and
emotional well-being.
f. Target Population:
i. Ages zero (0) to seventy (70).
ii. Males and females.
g.
Language:
i. English.
h. Medicaid Eligibility:
i. This service is Medicaid eligible, however the Contractor is not currently contracted with
the region 2 Regional Accountable Entity (RAE).
i. Service Access and Transportation:
i. In office at 2627 Redwing Road, Suite 235, Fort Collins, Colorado 80526.
ii. Telehealth.
2. Reunification Therapy
a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services
under this agreement:
i. Jan L. Faust, PhD for Reunification Family Therapy
ii. Child Parent Relational Therapy (CPRT)
1
iii. Trauma informed treatment
iv. Child centered play therapy
v. Psychoeducational training for parent/child
b. Anticipated Frequency of Services:
i. Four (4) to five (5) hours weekly. Meetings will take place with child and family
separately.
c. Anticipated Duration of Services:
i. Four (4) to six (6) months.
d. Goals of Services:
i. Improvement in interpersonal relationships.
ii. Increased feelings of safety.
iii. Improvement of communication skills.
iv. Improvement of co -parenting.
v. Identify the needs of the child and how parents can support those needs.
vi. Discuss parenting time outside of therapy sessions.
e. Outcomes of Services:
i. Reunification of identified client and non -time sharing parent.
ii. Reduced anxiety and improved co -parenting for both non -time and time sharing parents.
iii. Reduction in regressive behaviors in identified client.
f. Target Population:
i. Ages four (4) to seventeen (17).
ii. Males and females.
g. Language:
i. English
h. Medicaid Eligibility:
i. This service is not Medicaid eligible.
i. Service Access and Transportation:
i. In office 2627 Redwing Road, Suite 235, Fort Collins, Colorado 80526.
ii. Telehealth.
3. Therapeutic Visitation
a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services
under this agreement:
i. Child Parent Relational Therapy (CPRT).
ii. Trauma informed treatment
iii. Psychoeducational training for parents and child regarding development
b. Anticipated Frequency of Services:
i. Two (2) hours weekly.
c. Anticipated Duration of Services:
i. Six (6) to twelve (12) months. Duration will be decided by the Court or based on parent
availability.
d. Goals of Services:
i. Create a sense of safety and normalcy between relationships in therapy room.
ii. Identify needs of child and how parents can support those needs.
2
iii. Improve child's ability to identify own emotions.
iv. Improve child's ability to self -regulate.
v. Improve interpersonal relationships.
e. Outcomes of Services:
i. Continued visitation for maintenance of relationship between parent and child.
ii. Increased visitation times to further build upon relationship between child and parent —
potentially transitioning to reunification.
iii. A decrease in the need for visitation depending on the level of safety and care needed for
therapy sessions.
f. Target Population:
i. Ages four (4) to seventeen (17).
ii. Males and females.
g. Language:
i. English.
h. Medicaid Eligibility:
i. This service is not Medicaid eligible.
i. Service Access and Transportation:
i. In office at 2627 Redwing Road, Suite 235, Fort Collins, Colorado 80526.
ii. Telehealth.
Terms
1. Contractor will respond to the Quality Assurance Team(HS-CWQualityAssurance(a/weldgov.com within
three (3) business days regarding the ability to accept the received referral.
2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of
receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the
referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred
services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral
period, the Contractor will notify the caseworker and the Quality Assurance Team HS-
CWQualitvAssurance3f weldgov.com.
3. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated
absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then
Contractor understands that the Department will not reimburse for "no shows". Contractor understands that
the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the
part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will
place client on a behavioral plan requiring attendance or discharge the client from services. Contractor
must inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(&,weldgov.com
within three (3) days of when the client is placed on a behavioral plan or discharged
4. Contractor understands that the Department will not reimburse Contractor for cancelled appointments
either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a
"makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client
(excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the
Contractor must request a makeup session from the Department prior to the makeup session occurring
(excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the
3
caseworker and the Quality Assurance Team HS-CWQualityAssurance(&weldgov.com immediately via
email, to discuss service continuation.
5. Contractor will identify, in detail, areas of continued concern and make recommendations to the
caseworker in a monthly report regarding continuation of services and/or the need for additional services.
6. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom
the Contractor is working with under an active referral. Areas of concern may include, but are not limited
to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported to the
caseworker and the Quality Assurance Team HS-CWQualityAssurance(a,weldgov.com immediately
AND on the required monthly report.
7. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will
be submitted per the online format required by the Department, unless otherwise directed by the
Department.
8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core
Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals
will be approved by a new referral signed by the Child Welfare Supervisor. A change is defined as
anything outside of the approved documented service on the initial authorized referral form. This may
include an increase or decrease in services hours, change in frequency, change in location of services,
transportation needs, or any change to the initial referral or subsequent authorizations.
9. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings
include Court Facilitations, Bid Meetings, Professional Stuffings, Family Team Meetings and/or Team
Decision Making meetings. The Department will reimburse for actual participation in the meeting only so
long as there is written authorization from the Quality Assurance Team, and the facilitator documents in the
meeting notes the timeframe that the provider attended and when participation in the meeting is deemed
appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time
attended on the meeting notes. Staffings and/or meetings other than those listed above are not considered
reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator.
Contractor may participate by phone or virtually, if approved by the Department.
10. On a monthly basis, the Contractor will notify the Quality Assurance Team HS-
CWQualityAssurance(a/weldgov.com of new staff who will manage and/or administer the services with
the following information:
a. Staff member name and contact information
b. Education level/degree (if applicable)
c. Licensure/credentials (if applicable)
d. Department of Regulatory Authority (DORA) number (if applicable)
e. Supervisor name and contact information
The Department reserves the right to decline the new staff members managing and/or administering
services to Department clients.
4
EXHIBIT B
RATE SCHEDULE
1. Funding and Method of Payment
The Department agrees to reimburse the Contractor in consideration of the work and services performed
under this Agreement at the rate specific in Paragraph 2, below.
Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department
expenditures and shall not be reimbursed by the Department.
Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the
continuing availability of said funds for the purposes hereof. In the event that said funds, or any part
thereof, become unavailable as determined by the Department, the Department may immediately terminate
the Agreement or amend it accordingly.
2. Fees for Services
Mental Health Services _
Unit Type
Hour
Hour
Therapy
Unit Type
Hour
Hour
isitation
Unit Type
Hour
Hour
3. Submittal of Vouchers
Rate
$100.00
$100.00
Reunification
Rate
$125.00
Service Name
In-Office/Video
Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional
Staffing
$125.00
Therapeutic V
Rate
Service Name
In-Office/Video
Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional
Staffing
$100.00
$100.00
Service Name
In-OfficeNideo
Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional
Staffing
Contractor shall prepare and submit monthly a Request for Reimbursement and monthly report including
other supporting documentation, if applicable, certifying that services authorized were provided on the
date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 of this
Agreement .
Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department
by the 7° day of the month following the month of service, but no later than 45 days from the date of
service. Requests for Reimbursement and/or supporting documentation received after 45 days from the
date of service may result in delay or forfeiture of payment. Consistent failure to meet the 45 -day deadline
may result in termination of the Agreement.
For ongoing services, proof of services rendered shall be a monthly report submitted in accordance with
Paragraph 3(d) of this Agreement.
When submitting a request for payment for a one-time service, the contractor shall submit the first and last
page of the evaluation/report to confirm proof of services rendered. The full evaluation/report should be
submitted by the contractor to the caseworker.
For Monitored Sobriety services, proof of services rendered shall be the test result.
Exhibit C
WELD COUNTY'S REQUEST FOR PROPOSAL
(Weld County's Request for Proposal is incorporated into this agreement by reference and will
be provided upon request to the Department.)
This page is intentionally left blank
Exhibit D
Contractor's response to the Request for Proposal
Exhibit D contains the following documents:
• Attachment B — Provider Information Form (PIF)
• Attachment C — Proposal
• Attachment D — Staff Data Sheet
• Certificate of Insurance (COI)
L___
ATTACHMENT B
WELD COUNTY DEPARTMENT OF HUMAN SERVICES - PROVIDER INFORMATION FORM (PIF)
AGENCY INFORMATION
Agency Name: Our Village Counseling Trails Provider ID (if known):
Provider Contact Full Name: Dominic Joseph Smith Title: LPC,RPT Owner
Primary Phone Number (10 -digit): 970-658-7121 Ext.: Fax Number (lo -digit):
Primary Contact Email: DominicJ.Smith@outlook.com Web Address:
2627 Redwing Rd, STE 235, Fort Collins, CO 80526
Agency Location Address (Street, city, state, zip):
2627 Redwing Rd, STE 235, Fort Collins, CO 80526
Agency Mailing Address (Street, city, state, zip):
Agency Type (pick one): ® Public Company ® Private Non -Profit ® Private for Profit
Send Referrals for Service to:
Referral Contact Name: Dominic Smith Title: LPC,RPT Owner
Referral Phone Number (10 -digit): 970-658-7121 Ext.:
DominicJ.Smith@outlook.com
Email:
Billing Contact
Billing Contact Name: Dominic Smith
Billing Phone Number (lo -digit): 970-658-7121 hot.:
Title: LPC,RPT Owner
DominicJ.Smith@outlook.com
Email:
i I certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the specifications it i
I has so indicated in this bid form. I further affirm intention to enter into an agreement with Weld County, on behalf of the Weld County I
iDepartment of Human Services, and comply with all requirements of the contract, if awarded.
The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to accept
Ithe bid, or part of a bid, that, in the opinion of the Board, is in the best interests of the Board and of the County of Weld, State of I
Colorado. The Board of Weld County Commissioners shall give preference to resident Weld County bidders in all cases where the bids are ;
competitive in price and quality.
i WELD COUNTY IS EXEMPT FROM COLORADO SALES TAXES. THE CERTIFICATE OF EXEMPTION NUMBER IS #98-03551-0000.
Authorized Rep. Full Name: Dominic Smith Title: LPC,RPT Owner
i I
Authorized Rep. Email: DominicJ.Smith@outlook.com Phone (lo digit): 970-658-7121 hot.:
i 2627 Redwing Rd, STE 235, Fort Collins, CO 80526 i
Authorized Rep. Address (Street, city, state, zip):
il3' 8/8/2022 i
Signature of Authorized Rep.: Dominic Smith (Aug 31, 2022 16.36 MDT) Date: 1
REV. DECEMBER 2021
ATTACHMENT C - PROPOSAL
Please type your answers in the boxes below or check the appropriate box.
SECTION 1— Provider and Program Area Information
Bidder's Legal Name:
Our Village Counseling
Program Area: Mental Health Services Number of services offered on this Attachment C (max 5):
Program Areas are listed in column 1 of the table located in Item XI of the Request You may complete another Attachment C if you have more than 5.
for Proposal starting on page 13.
If
Service
2.1a
2.1b
2.1c
2.1d
2.1e
2.1f
2.1g
2.1h
2.1i
Service
2.2a
2.2b
2.2c
SECTION 2 - Service Name(s) and Information
the service is a monthly package, please offer different levels. All monthly packages must
state a specific minimum number of direct service hours.
#1 Name: Mental Health Services
Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points):
Child parent relational therapy
Play therapy
Cognitive behavioral therapy
Dialectical behavior therapy
Creative arts therapy
Trauma informed treatment
Psychoeducational training for parents/child regarding development
Anticipated frequency of direct service time with the client/family per week, not including professional staffing time,
administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level:
Once/twice weekly, 1-4 hours a week
Anticipated duration of service (i.e. 3-4 months):
4-6 months; depending on needs of family
Three (3), or more, specific goals of the service (DO use bullet points):
Greater integration of self
Greater coherence within a family system
Increase of desired behaviors, showing improvement in social and emotional well-being
Three (3), or more, specific outcomes of service:
Greater integration of self
Greater coherence within a family system
Increase of desired behaviors, showing improvement in social and emotional well-being
Target population of the service, including age and gender:
0-70 M/F
Languages service is available in (please list proficiency and if interpreter services are available):
N/A
Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part:
RMHP, Colorado Access, CHP+
Service location — list where the service will take place (i.e. client's home, in -office, other)
In -office, telehealth
#2 Name: Reunification Therapy
Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points):
Jan L Faust, PhD for Reunification Family Therapy
Child parent relational therapy (CPRT)
Trauma informed treatment
Child centered play therapy
Psychoeducational training for parents/child regarding development
Anticipated frequency of direct service time with the client/family per week, not including professional staffing time,
administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level:
4-5 hours weekly (Meeting with child, family separately)
Anticipated duration of service (i.e. 3-4 months):
REV. OCT 2021
ATTACHMENT C - PROPOSAL
4-6 months
2.2d Three (3), or more, specific goals of the service (DO use bullet points):
Improvement in interpersonal relationships
Increased feelings of safety
Improvement of communication skills
improvement of co -parenting
Identify needs of child and how parents can support those needs
Discuss parenting time outside of therapy sessions
2.2e Three (3), or more, specific outcomes of service:
Reunification of identified client and non -time sharing parent
Reduced anxiety and improved co -parenting for both non -time and time sharing parents
Reduction in regressive behaviors in identified client
2.2f Target population of the service:
4-17 M/F
2.2g Languages service is available in (please list proficiency and if interpreter services are available):
N/A
2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part:
RMHP, Colorado Access, CHP+
2.2i Service location — list where the service will take place (i.e. client's home, in -office, other)
2627 Redwing Rd, STE 235, Fort Collins, CO 80526
Service #3 Name:
Therapeutic Visitation (Not visitation)
2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points):
Child parent relational therapy (CPRT)
Trauma informed treatment
Psychoeducational training for parents/child regarding development
2.3b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time,
administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level:
2 hours a week
2.3c Anticipated duration of service (i.e. 3-4 months):
6-12 months, as decided by courts or others with ability to decide parenting time/scheduling.
2.3d Three (3), or more, specific goals of the service (DO use bullet points):
Create a sense of safety and normalcy between relationships in therapy room
Identify needs of child and how parents can support those needs
Improve child's ability to identify own emotions
Improve child's ability to self -regulate
Improve interpersonal relationships
2.3e Three (3), or more, specific outcomes of service:
Continued visitation for maintenance of a relationship between child and parent
Increased visitation times to further build upon relationship between child and parent — potentially transitioning to
reunification
Decrease of ceasing of visitation times depending on level of safety and care needed for therapy sessions
2.3f Target population of the service:
4-17 M/F
2.3g Languages service is available in (please list proficiency and if interpreter services are available):
N/A
2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part:
RMHP, Colorado Access, CHP+
2.3i Service location — list where the service will take place (i.e. client's home, in -office, other)
2627 Redwing Rd, STE 235, Fort Collins, CO 80526
Service #4 Name:
2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points):
2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time,
administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level:
REV. OCT 2021 2
ATTACHMENT C - PROPOSAL
2.4c Anticipated duration of service (i.e. 3-4 months):
2.4d Three (3), or more, specific goals of the service (DO use bullet points):
2.4e Three (3), or more, specific outcomes of service:
2.4f Target population of the service:
2.4g Languages service is available in (please list proficiency and if interpreter services are available):
2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part:
2.4i Service location — list where the service will take place (i.e. client's home, in -office, other)
Service #5 Name:
2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points):
2.5b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time,
administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level:
2.5c Anticipated duration of service (i.e. 3-4 months):
2.5d Three (3), or more, specific goals of the service (DO use bullet points):
2.5e Three (3), or more, specific outcomes of service:
2.5f Target population of the service:
2.5g Languages service is available in (please list proficiency and if interpreter services are available):
2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part
2.6i
Service location — list where the service will take place (i.e. client's home, in -office, other)
3.1
3.2 Will you conduct services in a client's home or in the community? Check one:
3.3 Will you transport clients to and/or from services? Check one: ❑ YES
3.4 How many miles are you willing to travel round trip? List a specific number of
miles.
3.5 When you calculate mileage, what is your starting point address?
Section 3 — Service Access and Transportation
Will you charge Weld County for transporting clients or mileage? Check one: ❑ YES ® NO
❑ YES ® NO
® NO
NA
Miles
NA
SECTION 4 — SERVICE RATES
All rates need to include administrative work (i.e. scheduling or report writing) and overhead.
Rates cannot be per episode, except for home studies and monitored sobriety testing.
Only hourly or monthly rates will be accepted for services, except for those listed above.
• For hourly rates complete section(s) 4.1-4.5.
• For monthly rates complete section 4.6.
REV. OCT 2021
ATTACHMENT C - PROPOSAL
• For Home study providers complete section 4.7.
• For monitored sobriety testing providers complete section 4.8.
4.1 Hourly Service #1 Name:
Mental Health Services or Individual and Family Therapy
4.1a In-Office/Video:
4.1b In -Office with Transportation:
In -Home or Community:
4.1c FTM, TDM, Prof. Staffing:
4.1d No show:
4.1e Mileage rate:
$ Amount
100.00
NA
NA
100.00
NA
NA
Unit Type
per Hour
per Hour No. of roundtrip miles included in rate:
per Hour No. of roundtrip miles included in rate:
per Hour
per No Show
per Mile This is paid after the miles listed above.
NA
NA
miles
miles
4.2 Hourly Service #2 Name:
Reunification Therapy
4.2a In-Office/Video:
4.2b In -Office with Transportation:
4.2c In -Home or Community:
4.2d FTM, TDM, Prof. Staffing:
4.2e No show:
4.2f Mileage rate:
$ Amount
125.00
NA
NA
125.00
NA
NA
Unit Type
per Hour
per Hour No. of roundtrip miles included in rate: I NA miles
per Hour No. of roundtrip miles included in rate: IL NA miles
per Hour
per No Show
per Mile This is paid after the miles listed above.
4.3 Hourly Service #3 Name:
Therapeutic Visitation
4.3a In-Office/Video:
4.3b In -Office with Transportation:
4.3c In -Home or Community:
4.3d FTM, TDM, Prof. Staffing:
4.3e No show:
4.3f Mileage rate:
$ Amount
100.00
NA
NA
100.00
NA
NA
Unit Type
per Hour
per Hour No. of roundtrip miles included in rate:
per Hour No. of roundtrip miles included in rate:
per Hour
per No Show
per Mile This is paid after the miles listed above.
NA
NA
miles
miles
4.4 Hourly Service #4 Name:
4.4a In-Office/Video:
4.4b In -Office with Transportation:
In -Home or Community:
4.4c FTM, TDM, Prof. Staffing:
4.4d No show:
4.4e Mileage rate:
$ Amount
Unit Type
per Hour
per Hour No. of roundtrip miles included in rate:
per Hour No. of roundtrip miles included in rate:
per Hour
per No Show
per Mile This is paid after the miles listed above.
miles
miles
4.5 Hourly Service #5 Name:
4.5a In-Office/Video:
4.5b In -Office with Transportation:
4.5c In -Home or Community:
4.5d FTM, TDM, Prof. Staffing:
4.5e No show:
4.5f Mileage rate:
$ Amount
Unit Type
per Hour
per Hour No. of roundtrip miles included in rate:
per Hour No. of roundtrip miles included in rate:
per Hour
per No Show
per Mile This is paid after the miles listed above.
miles
miles
4.6 Monthly Service Rates (each level must be listed):
Service Name with Level
Rate per Month
No. of Direct Service Hours:
4.6a
4.6b
4.6c
4.6d
REV. OCT 2021
4
ATTACHMENT C - PROPOSAL
4.6e
4.6f
4.6g
4.6h
4.6i
4.6j
4.7 Home Study Providers — List your rates in the box below.
4.8 Monitored Sobriety Providers — List your rates in the box below.
Provider special notes:
REV. OCT 2021
ATTACHMENT D - STAFF DATA SHEET
Bidder Must List All Staff Who Will Administer the Proposed Service(s)
BIDDER'S LEGAL NAME (As it appears on the W-9):
AGENCY CONTACT: Dominic Smith
Dominic Joseph Smith
PHONE NUMBER:970-658-7121
EMAIL: DominicJ.Smith@outlook.com
PROPOSED SERVICE(S): Mental Health Services
Legal Last Name
Middle
Initial
Previous Legal Last
Name (If applicable)
Legal First Name
Service Type
Licensure/
Credentials
DORA # (If applicable)
Smith
J
Dominic
Mental Health Services
LPC,RPT
LPC.0014731
CHILD WELFARE REQUEST FOR PROPOSAL 2022-23 - VARIOUS SERVICES
CPH
& ASSOCIATES
Certificate of Liability Insurance
Date Issued: 08/28/2022
PHILADELPHIA
INSURANCE COMPANIES
Underwritten by: Philadelphia Indemnity Insurance Company • One Bala Plaza, Suite 100 • Bala Cynwyd, PA 19004 • NAIC #: 18058
Administered by: CPH & Associates • 711 S. Dearborn St. Ste 205 • Chicago, IL 60605 • P 800.875.1911 • F 312.987.0902 • info@cphins.com
DISCLAIMER: This certificate is issued as a matter of information only and confers no rights upon the certificate holder. The Certificate of Insurance does not
constitute a contract between the issuing insurers), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend, or alter the coverage afforded by the policies listed thereon.
Insured: Our Village Counseling
Dominic Smith
2627 Redwing Road Ste 235
Fort Collins, CO 80526
Policy Number: AR188190
Policy Term: 09/09/2022 to 09/09/2023
Covered Locations
Professional Liability: Portable coverage, not location specific
Coverage Type Per Incident Aggregate
(Occurrence Form) (Per individual claim) (Total amount per year)
Professional Liability $ 1,000,000 $ 5,000,000
Supplemental Liability $ 1,000,000 $ 5,000,000
Licensing Board Defense $ 35,000 $ 35,000
Commercial General N/A N/A
Liability N/A N/A
Fire/Water Legal Liability
Business Personal Property N/A N/A
Cyber Liability
(Claims Made Form) $ 15,000 $ 15,000
Retroactive Date:
09/09/2022
Comments/Special Descriptions:
Certificate Holder
Weld County Department of Human Services
970-400-6210
822 7th St. Ste. 150
Greeley, CO 80632
Certificate Holder has been added as an additional insured
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does nA confer rights to the certificate holder in
lieu of such endorsement(s). Notice of Cancellation will only be provided to the first named insured in accordance with policy provisions, who shall act on behalf of all
additional insureds with respect to giving notice of cancellation.
(0,0146‘
Authorized Representative
C. Philip Hodson
SIGNATURE REQUESTED: Weld/Dominic,
Joseph Smith dba Our Village Counseling, LLC
- CPA with Exhibits A, B, C, D Attachments B,
C, D, COI
Final Audit Report
2022-08-31
Created: 2022-08-31
By: Windy Luna (wluna@co.weld.co.us)
Status: Signed
Transaction ID: CBJCHBCAABAARThl6a9ZcRFt8HkTKcY_Wol7gHTOTMyf
"SIGNATURE REQUESTED: Weld/Dominic Joseph Smith dba
Our Village Counseling, LLC - CPA with Exhibits A, B, C, D Attac
hments B, C, D, COI" History
t Document created by Windy Luna (wluna@co.weld.co.us)
2022-08-31 - 9:30:20 PM GMT
E4 Document emailed to Dominic Smith (dominicj.smith@outlook.com) for signature
2022-08-31 - 9:31:24 PM GMT
In Email viewed by Dominic Smith (dominicj.smith@outlook.com)
2022-08-31 - 10:35:18 PM GMT
4 Document e -signed by Dominic Smith (dominicj.smith@outlook.com)
Signature Date: 2022-08-31 - 10:36:37 PM GMT - Time Source: server
Q Agreement completed.
2022-08-31 - 10:36:37 PM GMT
Powered by
Adobe
Acrobat Sign
Contract Form
New Contract Request
Entity Information
Entity Name* Entity ID*
OUR VILLAGE COUNSELING LLC x00040030
Contract Name*
OUR VILLAGE COUNSELING, LLC (CHILD PROTECTION
AGREEMENT)
Contract Status
CTB REVIEW
❑ New Entity?
Contract ID
6294
Contract Lead*
WLUNA
Contract Lead Email
wlunavAweldgov.com;cobbx
xlkTTweldgov.com
Parent Contract ID
Requires Board Approval
YES
Department Project #
Contract Description*
NEW CHILD PROTECTION AGREEMENT. PROVIDER RELATED TO BID,' 62200040, TERM JULY 1. 2022 - MAY 31. 2023.
Contract Description 2
PA IS BEING ROUTED THROUGH THE NORMAL PROCESS. ETA TO CTB 09.05 2022.
Contract Type*
AGREEMENT
Amount*
80.00
Renewable*
NO
Automatic Renewal
Grant
IGA
Department
HUMAN SERVICES
Department Email
CM-
HumanServices,veldgov.co
Department Head Email
CM-HumanServic_es-
DeptHeadvVweldgov.com
County Attorney
GENERAL COUNTY
ATTORNEY EMAIL
County Attorney Email
CM-
COUNTYATTORNEY'Y W'ELDG
OV,COM
Requested BOCC Agenda
Date*
09 21 2022
Due Date
09 17 2022
Will a work session with BOCC be required?*
NO
Does Contract require Purchasing Dept. to be included?
If this is a renewal enter previous Contract ID
If this is part of a MSA enter NSA 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
Review Date*
03 31:2023
Renewal Date
Termination Notice Period
Contact Information
Contact Info
Contact Name
Purchasing
Committed Delivery Date
Expiration Date*
05 31;2023
Contact Type Contact Email Contact Phone I Contact Phone 2
Purchasing Approver Purchasing Approved Date
Approval Process
Department Head
JAMIE ULRICH
DH Approved Date
09/07/2022
Final Approval
BOCC Approved
BOCC Signed Date
BOCC Agenda Date
09 1412022
Originator
W'LUNA
Finance Approver
CHERYL P.ATTELLI
Legal Counsel
CAITLIN PERRY
Finance Approved Date Legal Counsel Approved Date
09.00,'2022 09:09,,2022
Tyler Ref #
AG 091422
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