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Home My WebLink About20211606.tiffCbn ack It t4 n1(e PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 29, 2022 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2021-22 Core/Non-Core Contracted Services B2100042 Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement Amendments for 2021- 22 Core/Non-Core Contracted Services B2100042. The Department entered into Agreements with various Child Welfare service providers through the 2021-2022 Request for Proposal (RFP), Bid Number: B2100042, identified as Tyler ID 2021-0307. These Agreements were issued for a period of three (3) years with the option to renew annually. The Department is requesting to renew the current Agreements with no changes for sixteen (16) providers reflected in the attached list. Agreements will be renewed for the second year for the period of June 1, 2022 through May 31, 2023. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Upon Board approval of this pass -around, signed Agreement Amendments will be obtained from providers and submitted to the Board for approval and Chair signature. I do not recommend a Work Session. I recommend approval of these Agreement Amendments and authorize the Chair to sign. Annrove Schedule Recommendation Work Session Perry L. Buck Mike Freeman, Pro -Tern F Scott K. James, Chair Steve Moreno Lori Saine VtL Pass -Around Memorandum; March 29, 2022 - CMS ID — Various Co1vtJ—fl-cy1icLc o5/OZ � Z2 Other/Comments: Page 1 ZpZI�� l001� PRIVILEGED AND CONFIDENTIAL Behavior Services of the Rockies B2100042 2021-22 2021-1581 Centennial Mental Health B2100042 2021-22 2021-1579 Colorado State University B2100042 2021-22 2021-1583 Hartshorn, Mandee dba Creative Nursing LLC B2100042 2021-22 2021-1437 Jones, Dr. Jacob B2100042 2021-22 2021-1470 Northern Colorado Counseling (Rascon, Christina) B2100042 2021-22 2021-1467 Northern Horizon Behavioral Health - Nikki Tolle B2100042 2021-22 2021-1436 Reaching Hope B2100042 2021-22 2021-1547 Reece, Alison B2100042 2021-22 2021-1438 Rocky Mountain Kids B2100042 2021-22 2021-1465 Sovereignty Counseling - Annette Brown B2100042 2021-22 2021-1439 Specialty Counseling & Consulting B2100042 2021-22 2021-1466 The Hope Initiative B2100042 2021-22 2021-1582 Tindall and Associates B2100042 2021-22 2021-1606 VitalCare B2100042 2021-22 2021-1469 Withers Whisper - Andrea Hall B2100042 2021-22 2021-1471 Pass -Around Memorandum; March 29, 2022 — CMS ID — Various Page 2 Karla Ford From: Sent: To: Subject: 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@welduov.com Website: www.co.weld.co.us In God We Trust Lori Saine Tuesday, March 29, 2022 11:34 AM Karla Ford RE: Please Reply - PA FOR ROUTING: CW Core Non -Core 2021-22 Renewals B2100042 (CMS Various) Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Karla Ford <kford@weldgov.com> Sent: Tuesday, March 29, 2022 10:45 AM To: Lori Saine <Isaine@weldgov.com> Subject: Please Reply - PA FOR ROUTING: Importance: High CW Core Non -Core 2021-22 Renewals B2100042 (CMS Various) Please advise if you approve recommendation. Thank you! Karla Ford 9 Executive Assistant & Office Manager, 1150 0 Street, P.O. Box 758, Greeley, :: 970.336-7204 :: kfordt?weldgov.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.** 1 t8 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND BREANNA TINDALL, PLLC This Agreement Amendment, made and entered into day of _ - , 2022 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human S ices, hereinafter referred to as the "Department", and Breanna Tindall, PLLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services and Sexual Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2021-1606, approved on June 21, 2021. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement will end on May 31, 2022. • This Amendment, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for the second year, for the period of June 1, 2022 through May 31, 2023. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTESTSi� C®• K+� Jerk to the Board Deputy Clerl(/o the ) OF COUNTY COMMISSIONERS COUNTY, COLORADO K. James, Chair MAY 0 2 2022 4feanna Tindall, PLLC 2629 Redwing Road Fort Collins, Colorado 80526 By: Jill Johr so, (Apr 21, 2022 09:03 MDT) Jill Johnson, Contract Manager Apr 21, 2022 Date: New Contract Request Entity Information Entity Name* Entity ID * ❑ New Entity? TINDALL, BARTELS, & ASSOCIATES, 97!0042212 LLC Contract Name * TINDALL, BARTELS, & ASSOCIATES, LLC (AGREEMENT AMENDMENT PY 2022-23) Contract Status CTB REVIEW Contract Description * BID# 62100042. TERM 6' 1 /22-5/31 ; 23. Contract Description 2 CONSENT: PA WAS SENT TO CTB ON: 3/ 30/2022. Contract ID 5776 Contract Lead APEGG Contract Lead Email apegg@DweIdgov.com; cobbx xlkweldgov.com Parent Contract ID 20211606 Requires Board Approval YES Department Project # Contract Type* Department Requested BOCC Agenda Due Date AMENDMENT HUMAN SERVICES Date* 0S21.2022 05-t'25,,2022 Amount* Department Email $0.00 CM- Will a work session with BOCC be required?* HumanServices@weldgov.co NO Renewable m NO Does Contract require Purchasing Dept. to be included? Department Head Email Automatic Renewal CM-HumanServices- DeptHead eldgov.com Grant County Attorney GENERAL COUNTY IGA ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY &WELDG 0V.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 OnBase Contract Dates Effective Date Review Date* Renewal Date 04/03,2023 Termination Notice Period Committed Delivery Date Expiration Date* 05/31x`2023 Contact Information Contact Info Contact Name Contact Type Contact Email Contact Phone I Contact Phone 2 Purchasing Purchasing r Purchasing Approved Date CONSENT 04/2212022 Approval Process Department Head Finance Approver Legal Counsel JAMIE ULRICH CONSENT CONSENT DH Approved Date Finance Approved Date Legal Counsel Approved Date 04122/2022 04/22/2022 04/22{2022 Final Approval ROCC Approved Tyler Ref # AG 050222 C signed Date ROCC Agenda Date 05/02/2022 Originator APEGG CHID PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND BREANNA TINDALL, PLLC This Agreement, made aid entered into th day o 2021, by and between the Board of Weld County Commissioners, on behalf of the Weld Cou Department of Human Services, hereinafter referred to as the "Department' and Breanna Tindall, PLLC, herein er 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 :his reference. Exhibit A is Weld County's Request for Proposal Number B2100042 which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to the Department for Mental Health Services and Sexual Abuse Treatment. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall became effective on June 1, 2021, upon proper execution of this Agreement and shall expire May 31, 2022, un_ess 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. Billir_g 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-CWOualityAssurance(a,weld2ov.com). No other Department staff or her party to the case may authorize services or modifications to services. c. Contractor agrees tc submit a complete Request for Reimbursement and supporting documentation by the 7th of the month. following the month of service, utilizing billing forms required by the Department. Contractor agrees to utilize the Client Verification Form for all scheduled and unscheduled face-to-face services with the exception of home studies and monitored sobriety testing. Contractor agrees tat original complete Client Verification Forms are to be submitted with the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received (i-MD) 2021-1606 Citi. 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 71 of the month, following the month of service, for each client receiving ongoing services. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Date and time of service b. Where the service took place c. Clinician/therapist name d. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will be the test result. A completed home study may be a full, partial or denied study, as determined by the Department. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. 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. 5. Financial Management 2 At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMG Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule: a. If services are funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. b. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. s q and its implementing regulation, 45 C.F.R. Part 80 et. sec ; 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. s 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 fuels 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 4 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- 1,03 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. 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 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. Monitorine 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). For Department: For Contractor: Heather Walker, Child Welfare Division Head Jill Johnson, Contract Manager 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich. Director P.O. Box A Greeley, Colorado 80632 (970) 400-6510 18. Litigation For Contractor: Jill Johnson. Contract Manager 2629 Redwing Road Fort Collins. Colorado 80526 (970) 290-3094 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 sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Imoronrieties/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 Emnlovee of Weld Coun 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 Aereement 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. Aereement 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, etc., generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Emnlovee Financial Interest/Conflict of Interest. C.R.S. 5524-18-201 et sea. 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 Anoroval 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. ATTEST: Weld C ant Clerk to the Board ( By: \-" Deputy Clerk to 1861 13 BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Moreno, Chair JUN 2 12021 Breanna Tindall, PLLC 2629 Redwing Road Fort Collins, Colorado 80526 (970) 290-3094 4�,-70�2�1I0`1 By: Jill Johnson (Jun 11,2021 1600 MDT) Jill Johnson, Contract Manager Date: Jun 11, 2021 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.) 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Exhibit B Contractor's response to the Request for Proposal Exhibit B contains the following documents: • Attachment B — Provider Information Form (PIF) • Attachment C — Proposal • Attachment D — Staff Data Sheet • Certificate of Insurance (COI) ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES — PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION Agency Name: Dr. Brenna Tindall, LLC & Associates Trails Provider ID (if known): Provider Contact Full Name: Jill Johnson Primary Phone Number (10 -digit): (970)290-3094 Ext.: jill@tindall-bartels.com Primary Contact Email: Title: Contracts Manager Fax Number (10 -digit): Web Address: drbrennatindall.com Agency Location Address (Street, city, state, zip): 2629 Redwing Rd., Ft.Collins CO 80526 Agency Mailing Address (Street, city, state, zip): PO Box 272595 Ft.Collins, CO 80527 Agency Type (pick one): flPublic Company Private Non -Profit ✓❑ Private for Profit Send Referrals for Service to: Referral Contact Name: Kathy Travis Title: Scheduling Coordinator (970)231-9611 scheduling@tindall-bartels.com Referral Phone Number (10 -digit): Ext.: Email: Billing Contact Billing Contact Name: Jill Johnson Billing Phone Number (10 -digit): (970)290-3094 Ext Title: Contract Manager billing@tindall-bartels.com Email: CERTIFICATION ; I 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 behalf of the Weld County Department of Human Services, and comply with all requirements of the contract, if awarded. The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to accept 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, i State of Colorado. The Board of Weld County Commissioners shall give preference to resident Weld County bidders in all cases where the bids are competitive in price and quality. Authorized Rep. Full Name: Jill Johnson Title: Contracts Manager Authorized Rep. Email: jill@tindall-bartels.com Phone (10 -digit): (970)290-3094 Ext.: Authorized Rep. Address (Street, city 629 Redwing Rd., Ft.Collins CO 80526 state, zip): i 01/25/2021 f Signature of Authorized Rep.: �._ Date: L---------------------------------------------------------------------------------1 REV. NOVEMBER 2020 ATTACHMENT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1 Provider and Program Area Information Bidder's Legal Name: Dr. Brenna Tindall, LLC & Associates Program Mental Health Services Number of services offered on this Exhibit C (max 3 Area: 5): 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 S. for Proposal starting on page 13. SECTION 2 - Service Name(s) and Information Service #1 Name: Cognitive Evaluations 2.1a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): In -person evaluations using cognitive testing if needed. 2.1b Anticipated frequency of service per week (i.e. 4 hours/week): We have 3 office locations and 3 clinicians, so are able to do all evaluations within a reasonable amount of time, and some on short -notice. The hours depend on the extent of the evaluation. 2.1c Anticipated duration of service (i.e. 3-4 months): Dependent on the extent of evaluation. Typically completed within 90 days. 2.1d Three (3). or more, specific eoals of the service (DO use bullet points): • Goals of the service determined based on the referral question, the clinician will work with the referral source to determine the appropriate type of evaluation to answer the referral question. • Assess cognitive functioning areas based on referral question, potentially including IQ, achievement, and adaptive functioning • Recommendations offered based on answers to referral questions. • Testing used may include: WAIS-IV, WISC-V, WRAT-5, WIAT-III, Vineland -3, SRS -2 2.1e Three • • 2.1f Three or outcomes of service: Answer identified referral questions Appropriately assess client's current level of cognitive functioning Provide clinical insight related to client's level of cognitive functioning Timely evaluation report of the We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): I Possibility of Spanish interpretation if not available from the referral source. 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #2 Name: 2.2a Mod: 2.2b Trauma Evaluations curriculum, tools used in delivery of service (DO NOT list evaluations using psychological testing if needed. d frequency of service per week (i.e. 4 hours/week): Determined per case. 2.2c Anticipated duration of service (i.e. 3-4 months): Dependent on Client. Tvnically completed within 90 2.2d Three (3). or of the service (DO use bullet DO use bullet • Goals of the service determined based on the referral question, the clinician will work with the referral source to determine the appropriate type of evaluation to answer the referral question. • Assess client's level of trauma and impact of trauma as it relates to the referral question. • Recommendations offered based on answers to referral questions. REV. NOV 2019 1 ATTACHMENT C - PROPOSAL TEMPLATE • Testing used may include: MMPI-2, MMPI-A, MMPI-2-RF, MMPI-A-RF, MACI, MCMI-IV, TSCC, TSI-2, Rorschach, PAI, PAI-A 2.2e Three (3), or more, specific outcomes of service: • Answer identified referral questions • Appropriately assess client's current level of trauma and trauma symptomology • Provide clinical insight related to client's trauma symptomology • Timely evaluation report 2.2f Target Donulation of the service: We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.2g Languages service is available in (please list proficiency and if interpreter services are Possibility of Spanish interpretation if not available from the referral source. 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in pa: Service #3 Name: 2.3a Moth Psychological evaluations (including full psychological evaluations) evaluations tools used in of service (DO NOT list in if needed. DO use bullet 2.3b Anticipated frequency of service per week (i.e. 4 hours/week): Determined per case. Assessments are typically 3-5 hours of direct client contact with a psychologist. 2.3c Anticipated duration of service (i.e. 3-4 months): Determined per case. Typically completed within 90 days. 2.3d Three (3), or more, specific goals of the service (DO use bullet points): • Goals of the service to answer questions about psychological variables (emotional state, personality, pathology, behavior and cognitive/intellectual ability using formal testing, collateral information and clinical judgement. • The evaluator provides a comprehensive conceptualization (including mental health diagnosis) of the individual that answers the referral question and provides greater insight and clarity into his/her psychological functioning. • The evaluator provides recommendations that will likely be most effective and efficient in meeting the parent's and/or child's needs. • The evaluation can be useful in assessing the strengths and weaknesses of an individual and how these can impact the individual's capacity to parent a child. • Recommendations offered based on answers to referral question. 2.3e Three (3), or more, specific outcomes of service: Determined per case 2.3f Target population of the service: We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.3g Languages service is available in (please list proficiency and if interpreter services are available): We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.3h Medicaid eligibility — list whether the service is elieible for Medicaid in whole or in Dart: Service #4 Name: 2.4a Moth 2.4b Antici 2.4c Antici F 2.4d Three 2.4e Three 2.4f Targe REV. NOV 2019 , curriculum, tools used in delivery of service (DO NOT list d frequency of service per week (i.e. 4 hours/week): d duration of service (i.e. 3-4 months): or more. specific goals of the service (DO use bullet points): or more. specific outcomes of service: of the service: DO use bullet 2 2.4g Languag� 2.4h Medicaid I Service #5 Name: 2.5a Modalitic 2.Sb Anticipat 2.5c Anticipat 2.5d Three 3 2.5e Three 3. 2.Sf Target pa 2.5g Languagt ATTACHMENT C - PROPOSAL TEMPLATE service is available in (please list proficiency and if interpreter services are availa — list whether the service is eligible for Medicaid in whole or in , curriculum, tools used in delivery of service (DO NOT list d frequency of service per week (i.e. 4 hours/week): d duration of service (i.e. 3-4 months): or more, specific foals of the service (DO use bullet points): or more, specific outcomes of service: of the service: service is available in (please list and if services are 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part DO use bullet Section 3 — Service Access and Transportation 3.1 Will you conduct services in your office? 3.1a If yes, office location(s): Yes 3 locations: 918 13th Street, #2, Greeley, CO 80631; 2629 Redwing Road, #140, Fort Collins, CO 80526; 8811 E. Hampden Avenue, #202, Denver, CO 80631. 3.2 Will you conduct services out of the office? j Yes 3.2a If yes, how many miles will you travel from your office? 3.3 Will you transport clients to and from services? 3.3a If yes, what is your starting point address? No Within 30 mile radius 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: 4.1 a 4.l b 4.l c 4.ld REV. NOV 2019 Cognitive Evaluations In -Office rate: Out -of -office rate: FTM, TDM, Prof. Staffing: No show: $ Amount $300 per $300 hou r , per per Unit Type hour hour Hour Catchment area in miles: 30 Miles 7 ATTACHMENT C - PROPOSAL TEMPLATE 4.1e Mileage rate after $.57 per catchment: 4.1f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: 4.2 Service #2 Name: 4.2a 4.2b L 4.4 Trauma Evaluations In -Office Rate: Out -of -Office Rate: 4.2c FTM, TDM, Prof. Staffing: 4.2d No show: 4.2e Mileage rate after catchment: $ Amount $300 per $300 per I $150 I S.57 4.2f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: Service #3 Name: 4.3a 4.3b per per per Mile nplete the boxes below. per month per month per month per month Unit Type Hour Hour Hour Mile Catchment area in miles: nplete the boxes below. per month per month per month per month Psychological evaluations (including full psychological evaluations) In -Office Rate: Out -of -Office Rate: 4.3c FTM, TDM, Prof. Staffing: 4.3d No show: 4.3e Mileage rate after catchment: 4.3f Service #4 Name: $ Amount $300 per $300 per I $150 I If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: $ Amount 4.4a 4.4b In -Office Rate: Out -of -Office Rate: 4.4c FTM, TDM, Prof. Staffing: 4.4d No show: 4.4e Mileage rate after catchment: 4.4f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: Unit Type Hour Hour per Hour per per Mile per per per per per Mile 30 Miles Catchment area in 30 Miles miles: nplete the boxes below. per month per month per month per month Catchment area in miles: nplete the boxes below. per month per month per month per month Miles REV. NOV 2019 4 ATTACHMENT C - PROPOSAL TEMPLATE 4.5 Service #5 Name: $ Amount 4.5a 4.5b In -Office Rate: Out -of -Office Rate: 4.5c FTM, TDM, Prof. Staffing: 4.5d No show: 4.5e Mileage rate after catchment: per per per per per Mile 4.5f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: 4.6 Home Study Providers — List your rates in the box below. 4.7 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: Translator can be for $120 flat fee for evaluations or Catchment area in miles: nplete the boxes below. per month per month per month per month 15 minutes on an as -needed basis. Miles REV. NOV 2019 5 ATTACHMENT C - PROPOSAL TEMPLATE Please type your answers in the boxes below. SECTION 1— Provider and Program Area Information Bidder's Legal Name: Dr. Brenna Tindall, LLC & Associates Program Mental Health Services Number of services offered on this Exhibit C (max 4❑ Area: 5): Program Areas are listed in column 1 of the table located in Item XI of the Request You may complete another Exhibit C i'you have more than S. for Proposal starting on page 13. SECTION 2 — Service Name(s) and Information Service #1 Name: Offense Specific Evaluations 2.1a Modalities. curriculum, tools used in delivery of service (DO NOT list comnanv history: DO use bullet noints): In -person evaluations using psychological testing if needed. 2.1b Anticipated frequency of service per week (i.e. 4 hours/week): We have 3 office locations and 3 clinicians, so are able to do all evaluations within a reasonable amount of time, and some on short -notice. The hours depend on the extent of the evaluation. 2.1c Anticipated duration of service (i.e. 3-4 months): Dependent on the extent of evaluation. Typically completed within 90 days. 2.1d Three (3), or more, specific goals of the service (DO use bullet points): Adult SOMB/DVOMB Standards: • The purpose of a mental health sex offense -specific evaluation (hereafter evaluation) is to assess a client's need for treatment, determine what type of treatment is needed, and identify the risk level and any additional needs the client may have. • Treatment considerations should be based on the conclusions and recommendations of the evaluation. While the evaluation provides valuable information and recommendations, it should be viewed as fluid. As new information emerges, or risk level changes within the course of treatment, a client's treatment should be tailored to address those changes. • Because of the importance of the initial information to subsequent sentencing, supervision, treatment, and behavioral monitoring, each client shall receive a thorough assessment and evaluation that examines the interaction between the client's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. • Sex offense -specific evaluations are not intended to replace more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner, regardless of the client's status within the criminal justice system. • Evaluations recommending sex offense -specific treatment should suggest the use of research informed treatment, management, and monitoring interventions that are appropriate for the risk level, needs, and responsivity of each individual client and that minimize that client's likelihood to sexually reoffend. • Consequently, evaluators will prioritize the physical and psychological safety of victims and potential victims in making recommendations that are appropriate to the assessed risk and needs of each client. • Various stakeholders, including lawyers, judges, supervising officers, treatment providers and others, rely upon evaluations to make informed decisions at multiple points in time. • Evaluators should not assume that readers possess clinical training or expertise in mental health treatment, and should attempt to minimize overemphasis on any single test or aspect of the assessment. • Evaluation(s) shall be conducted to identify the following factors: risk of re -offense and/or further abuse, offender criminogenic needs, offender responsivity to treatment, and other treatment issues as identified in Section 4.08 "Required Minimum Sources of Information." These factors shall assist in determining recommendations regarding offender treatment. REV. NOV 2019 1 ATTACHMENT C - PROPOSAL TEMPLATE • Evaluation(s) shall result in an initial offender Treatment Plan with the understanding that assessment is an ongoing process, which may necessitate changes to the plan. • Evaluation(s) shall direct initial placement of the offender into the appropriate level and intensity of treatment as identified in Standard 5.06. • Identification of individual criminogenic factors/needs (Reference Appendix E, Section IV) - Identification of strategies for managing criminogenic factors/needs and potential destabilizing factors - Identification of offender strengths (e.g., pro -social support, employment, education) - Initial recommendations for treatment planning - Initial recommendations for offender monitoring related to community and victim safety, if applicable - Assessment of offender responsivity (Reference Appendix E, Section VI) - Assessment of offender accountability (Reference Appendix E, Section I) - Assessment of amenability for treatment is defined as: The ability to comprehend treatment concepts The physical and mental ability to function in a treatment setting — • Juvenile SOMB Standards: • Evaluations are conducted to identify levels of risk and specific risk factors that require attention in treatment and supervision, and to assist the court in determining the most appropriate sentence for juveniles. Due to the importance of the information to subsequent sentencing, supervision, treatment and behavioral monitoring, each juvenile who has committed a sexual offense shall receive a thorough assessment and evaluation that examines the interaction of the juvenile's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. • A thorough review of relevant prior treatment and supervision information can aid in the planning of treatment needs for the client and ensure continuity of care. To this end, it is imperative that the Evaluator make every reasonable effort to identify and obtain past records to determine what treatment may have been completed, what components of treatment need additional focus, and what components of treatment have not yet been completed. • Sex offense specific evaluations are not intended to supplant more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner regardless of the juvenile's status within the criminal justice system. • The evaluation of juveniles who have committed sexual offenses shall be comprehensive. • Recommendations for intervention shall be included in the summary and the evaluation shall be provided in written form to the referring agent. • The evaluation of juveniles who have committed sexual offenses has the following purposes: A. To assess overall risk to the community; B. To provide protection for victims and potential victims; C. To provide written clinical assessment of a juvenile's strengths, risks and needs; D. To identify and document treatment and developmental/cognitive needs; E. Prior treatment involvement; F. To identify individual differences, potential barriers to treatment, and static and dynamic risk factors; G. To make recommendations for the management and supervision of the juvenile; H. To provide information which can help identify the type and intensity of community based treatment, or the need for a more restrictive setting. 2.1e Three (3), or more, specific outcomes of service: • Answer identified referral questions • Appropriately assess client's strengths, risks and needs • To make recommendations for the management and supervision of the juvenile • Timely evaluation report 2.1f Target population of the service, including age and gender: REV. NOV 2019 2 ATTACHMENT C - PROPOSAL TEMPLATE We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.lg Languages service is available in (please list proficiency and if interpreter services are available): Possibility of Spanish interpretation if not available from the referral source. 2.1h Medicaid Service #2 Name: — list whether the service is eligible for Medicaid in whole or in ID/DD Offense Specific Evaluations 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list corn In -person evaluations using psychological testing if needed. 2.2b Anticipated frequency of service per week (i.e. 4 hours/week): Determined per case. 2.2c Anticipated duration of service (i.e. 3-4 months): on Client. 2.2d Three(3), or more, specific Adult Standards: )mpleted within 90 days. of the service (DO use bullet DO use bullet • The purpose of a mental health sex offense -specific evaluation (hereafter evaluation) is to assess a client's need for treatment, determine what type of treatment is needed, and identify the risk level and any additional needs the client may have. • Treatment considerations should be based on the conclusions and recommendations of the evaluation. While the evaluation provides valuable information and recommendations, it should be viewed as fluid. As new information emerges, or risk level changes within the course of treatment, a client's treatment should be tailored to address those changes. • Because of the importance of the initial information to subsequent sentencing, supervision, treatment, and behavioral monitoring, each client shall receive a thorough assessment and evaluation that examines the interaction between the client's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. • Sex offense -specific evaluations are not intended to replace more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner, regardless of the client's status within the criminal justice system. • Evaluations recommending sex offense -specific treatment should suggest the use of research informed treatment, management, and monitoring interventions that are appropriate for the risk level, needs, and responsivity of each individual client and that minimize that client's likelihood to sexually reoffend. • Consequently, evaluators will prioritize the physical and psychological safety of victims and potential victims in making recommendations that are appropriate to the assessed risk and needs of each client. • Various stakeholders, including lawyers, judges, supervising officers, treatment providers and others, rely upon evaluations to make informed decisions at multiple points in time. • Evaluators should not assume that readers possess clinical training or expertise in mental health treatment, and should attempt to minimize overemphasis on any single test or aspect of the assessment. • Conducted per Standards/Guidelines specific to ID/DD clients. Juvenile Standards: • Evaluations are conducted to identify levels of risk and specific risk factors that require attention in treatment and supervision, and to assist the court in determining the most appropriate sentence for juveniles. Due to the importance of the information to subsequent sentencing, supervision, treatment and behavioral monitoring, each juvenile who has committed a sexual offense shall receive a thorough assessment and evaluation that examines the interaction of the juvenile's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. • A thorough review of relevant prior treatment and supervision information can aid in the planning of treatment needs for the client and ensure continuity of care. To this end, it is imperative that the REV. NOV 2019 3 Evaluator make every reasonable effort to identify and obtain past records to determine what treatment may have been completed, what components of treatment need additional focus, and what components of treatment have not yet been completed. • Sex offense specific evaluations are not intended to supplant more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner regardless of the juvenile's status within the criminal justice system. • The evaluation of juveniles who have committed sexual offenses shall be comprehensive. • Recommendations for intervention shall be included in the summary and the evaluation shall be provided in written form to the referring agent. • The evaluation of juveniles who have committed sexual offenses has the following purposes: A. To assess overall risk to the community; B. To provide protection for victims and potential victims; C. To provide written clinical assessment of a juvenile's strengths, risks and needs; D. To identify and document treatment and developmental/cognitive needs; E. Prior treatment involvement; F. To identify individual differences, potential barriers to treatment, and static and dynamic risk factors; G. To make recommendations for the management and supervision of the juvenile; H. To provide information which can help identify the type and intensity of community based treatment, or the need for a more restrictive setting • Conducted per Standards/Guidelines specific to ID/DD clients. 2.2e Three (3), or more, specific outcomes of service: • Answer identified referral questions • Appropriately assess client's strengths, risks and needs • To make recommendations for the management and supervision of the juvenile • Timely evaluation report 2.2f Target population of the service: We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.2g Languages service is available in (please list proficiency and if interpreter services are available Possibility of Spanish interpretation if not available from the referral source. 2.2h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #3 Name: 2.3a Modalities, cui No -refundable 2.3b Consultation Services , tools used in delivery of service nent fee for consultation services. of service ner week (i.e. 4 hours/v Determined per case 2.3c Antici ated duration of service Determined per case. Typically 2.3d Three (3). or more, specific eoa NOT list (i.e. 3-4 months): within 2 weeks of services/intake assessment. .s of the service (DO use bullet points): DO use bullet • Analyzing a client's case/assessments to help determine a referral source for the most cost-effective, evidence based, collaborative, trauma -informed approach to create a treatment plan and/or supervision plan. • Assisting in case review/conceptualization with DHS staff via phone calls, emails and all associated parties. • Participation in staffing's, family meetings, etc. via phone or in person. • Providing the department research if requested. • Reviewing case records and providing informal risk assessments. • Assisting DHS staff in finding appropriate professionals to help meet treatment needs to mitigate safety concerns and issues that led to child welfare involvement. REV. NOV 2019 4 ATTACHMENT C - PROPOSAL TEMPLATE • Helping to create and appropriate intervention and/or strategy based upon the risk-need-responsivity (RNR). • Provide expert testimony and preparation of summary reports and recommendations. 2.3e Three (3), or more, specific outcomes of service: • Answer identified referral questions 2.3f Target population of the service: We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.3g Languages service is available in (please list proficiency and if interpreter services are availa Possibility of Spanish interpretation if not available from the referral source. 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #4 LOOK Assessment Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company his Look Assessment 2.4b Anticipated frequency of service per week (i.e. 4 hours/week): Determined per case. 2.4c Anticipated duration of service (i.e. 3-4 months): Determined per case. 2.4d Three (3), or more, specific goals of the service (DO use bullet points): • Administration of LOOK assessment compliant with assessment guidelines. • Additional administration of assessment if warranted • Report outlining results of the assessment. 2.4e Three (3), or more, specific outcomes of service: Determined per case. 2.4f Target population of the service: We conduct evaluations for all ages, all genders, all races, including DD/ID, LGBTQ. 2.4g Languages service is available in (please list proficiency and if interpreter services are Possibility of Spanish interpretation if not available from the referral source. 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in Da: Service #5 Name: 2.5a Moth 2.5b tools used in delivery of service (DO NOT list of service per week (i.e. 4 h 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 2.5e Three (3), or more, specific outcomes of service: 2.5f Target nonulation of the service: DO use bullet DO use bullet Doints): 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 Dart Section 3 — Service Access and Transportation 3.1 Will you conduct services in your office? Yes REV. NOV 2019 5 ATTACHMENT C - PROPOSAL TEMPLATE 3.1a If yes, office location(s): 3 locations: 918 13th Street, #2, Greeley, CO 80631; 2629 Redwing Road, #140, Fort Collins, CO 80526; 8811 E. Hampden Avenue, #202, Denver, CO 80631. 3.2 Will you conduct services out of the office? Yes 3.2a If yes, how many miles will you travel from your office? 3.3 Will you transport clients to and from services? 3.3a If yes, what is your starting point address? No Within 30 mile radius 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: 4.1a 4.l b 4.1c 4.I d 4.1 e Offense Specific Evaluations In -Office rate: Out -of -office rate: FTM, TDM, Prof. Staffing: No show: Mileage rate after catchment: Amount $300 per $300 1 per $150 per per $.57 per 4.1f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: 4.2 Service #2 Name: 4.2a 4.2b DD Offense Specific Evaluations In -Office Rate: Out -of -Office Rate: 4.2c FTM, TDM, Prof. Staffing: 4.2d No show: 4.2e Mileage rate after catchment: $ Amount $300 per $300 per $150 per per $.57 4.2f If the rate(s) listed above are a monthly No. of Face-to-face hours: No. of admin/case management hours: No. of travel hours TOTAL HOURS: 4.3 Service #3 Name: 4.3a REV. NOV 2019 Consultation Services Unit Type Hour Hour Hour Mile Catchment area in 30 Miles miles: mplete the boxes below. per month per month per month per month Unit Type Hour Hour Hour per Mile Catchment area in 30 Miles miles: replete the boxes below. per month per month per month per month $ Amount Unit Type In -Office Rate: $150 per Assessment ATTACHMENT C - PROPOSAL TEMPLATE 4.3b Out -of -Office Rate: per Catchment area in 30 Miles miles: 4.3c FTM, TDM, Prof. Staffing: per 4.3d No show: per 4.3e Mileage rate after $.57 per Mile catchment: 4.3f If the rate(s) listed above are a monthly acka e, 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 The LOOK Assessment Name: $ Amount Unit Type 4.4a In -Office Rate: $300 per Assessment 4.4b Out -of -Office Rate: per Catchment area in 30 Miles miles: 4.4c FTM, TDM, Prof. Staffing: per 4.4d No show: per 4.4e Mileage rate after $.57 per Mile catchment: 4.4f If the rate(s) listed above are a monthly acka e, 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 In -Office Rate: Out -of -Office Rate: per per Catchment area in Miles miles: 4.5c FTM, TDM, Prof. Staffing: per 4.5d No show: per 4.5e Mileage rate after catchment: per Mile 4.5f If the rate(s) listed above are a monthly acka e, 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 4.6 Home Study Providers — List your rates in the box below. 4.7 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: Translator can be for $120 flat fee for evaluations or $10/per 15 minutes on an as -needed basis. REV. NOV 2019 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:JIII Johnson Dr. Brenna Tindall, LLC PHONE NUMBER:(970)290-3094 EMAIL: jill @tindall-bartelscorn PROPOSED SERVICE(S): Mental Health/EvaluatuonS Legal. Last Name Middle Initial Previous Legal Last Name. (If applicable) Legal First Name Service Type Licensure/ Credentials DORA # (If applicable). Tindall Brenna Mental Health Licensed Psychologist PSY.0003709 1 CHILD WELFARE REQUEST FOR PROPOSAL 2021-22 - VARIOUS SERVICES BID NO. 82100042 ACOR 1 0 C" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/11/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Trust Risk Management Services, Inc. 1791 Paysphere Circle NAME: Trust Risk Management Services, Inc PHONE A/C, No, Ext : 877.637.9700 FAX A/C, NO): 877.251.5111 EMAIL Chicago, IL 60674 ADDRESS: info@trustrms.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: ACE American Insurance Company 22667 INSURED Dr. Jessi Bartels INSURER B: Tindall, Bartels, & Associates INSURER C: 1122 9Th St Ste 203 INSURER D: INSURER E: Greeley, CO 80631 3277 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS MADE X❑ OCCUR Y Y D42201601 09/062020 09/06/2021 DAMAGE TO RENTED PREMISES (Ea occurrence) $1,000,000 X MED EXP (Any one person) $10,000 Contractual Liability PERSONAL & ADV INJURY $1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 GEN'L X PRO- POLICY JECT L.JLOC PRODUCTS—COMP/OP AGG $2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY (Per Person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS I AUTOS BODILY INJURY (Per accident $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER I 10TH- $ AND EMPLOYERS LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE N /A STATUTE I IER BLEACH ACCIDENT $ E.L. DISEASE -EA EMPLOYE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required): Board Of county Commissioners of Weld County and its Officers/Employee are included as additional insureds. CERTIFICATE HOLDER CANCELLATION Additional Insured SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Weld County 1150 O Street BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Greeley, CO, 80631 ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD EXHIBIT C SCOPE OF SERVICES Contractor will provide Mental Health Services and Sexual Abuse Treatment, as referred by the Department. Offense Specific Evaluations a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. In -person evaluations using psychological testing as needed. b. Anticipated Frequency of Services: i. Dependent upon the extent of the evaluation needed. c. Anticipated Duration of Services: i. Typically completed within a 90 -day period. d. Goals of Services: Adult Sex Offender Management Board (SOMB)/Domestic Violence Offender Management Board (DVOMB) Standards: 1. To assess a client's need for treatment, determine what type of treatment is needed, and identify the risk level and any additional needs the client may have. 2. Treatment considerations should be based on the conclusions and recommendations of the evaluation. While the evaluation provides valuable information and recommendations, it should be viewed as fluid. As new information emerges, or risk level changes within the course of treatment, a client's treatment should be tailored to address those changes. 3. Because of the importance of the initial information to subsequent sentencing, supervision, treatment, and behavioral monitoring, each client shall receive a thorough assessment and evaluation that examines the interaction between the client's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. 4. Sex offense -specific evaluations are not intended to replace more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner, regardless of the client's status within the criminal justice system. 5. Evaluations recommending sex offense -specific treatment should suggest the use of research informed treatment, management, and monitoring interventions that are appropriate for the risk level, needs, and responsivity of each individual client and that minimizes a client's likelihood to sexually reoffend. 6. Evaluators will prioritize the physical and psychological safety of victims and potential victims in making recommendations that are appropriate to the assessed risk and needs of each client. 7. Various stakeholders, including lawyers, judges, supervising officers, treatment providers and others, rely upon evaluations to make informed decisions at multiple points in time. 8. Evaluators should not assume that readers possess clinical training or expertise in mental health treatment, and should attempt to minimize overemphasis on any single test or aspect of the assessment. 9. Evaluation(s) shall be conducted to identify the following factors: risk of re - offense and/or further abuse, offender criminogenic needs, offender responsivity to treatment, and other treatment issues as identified in Section 4.08 "Required Minimum Sources of Information." These factors shall assist in determining recommendations regarding offender treatment. 10. Evaluation(s) shall result in an initial offender Treatment Plan with the understanding that assessment is an ongoing process, which may necessitate changes to the plan. 11. Evaluation(s) shall direct initial placement of the offender into the appropriate level and intensity of treatment as identified in Standard 5.06. 12. Identification of individual criminogenic factors/needs (Reference Appendix E, Section IV) - Identification of strategies for managing criminogenic factors/needs and potential destabilizing factors - Identification of offender strengths (e.g., pro -social support, employment, education) - Initial recommendations for treatment planning - Initial recommendations for offender monitoring related to community and victim safety, if applicable - Assessment of offender responsivity (Reference Appendix E, Section VI) - Assessment of offender accountability (Reference Appendix E, Section I) - Assessment of amenability for treatment is defined as: The ability to comprehend treatment concepts The physical and mental ability to function in a treatment setting. ii. Juvenile SOMB Standards 1. Evaluations are conducted to identify levels of risk and specific risk factors that require attention in treatment and supervision, and to assist the court in determining the most appropriate sentence for juveniles. Due to the importance of the information to subsequent sentencing, supervision, treatment and behavioral monitoring, each juvenile who has committed a sexual offense shall receive a thorough assessment and evaluation that examines the interaction of the juvenile's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. 2. A thorough review of relevant prior treatment and supervision information can aid in the planning of treatment needs for the client and ensure continuity of care. To this end, it is imperative that the Evaluator make every reasonable effort to identify and obtain past records to determine what treatment may have been completed, what components of treatment need additional focus, and what components of treatment have not yet been completed. 3. Sex offense specific evaluations are not intended to supplant more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner regardless of the juvenile's status within the criminal justice system. 4. The evaluation ofjuveniles who have committed sexual offenses shall be comprehensive. 5. Recommendations for intervention shall be included in the summary and the evaluation shall be provided in written form to the referring agent. 6. The evaluation ofjuveniles who have committed sexual offenses has the following purposes: A. To assess overall risk to the community; B. To provide protection for victims and potential victims; C. To provide written clinical assessment of a juvenile's strengths, risks and needs; D. To identify and document treatment and developmental/cognitive needs; E. Prior treatment involvement; F. To identify individual differences, potential barriers to treatment, and static and dynamic risk factors; G. To make recommendations for the management and supervision of the juvenile; H. To provide information which can help identify the type and intensity of community based treatment, or the need for a more restrictive setting. e. Outcomes of Services: i. Answer identified referral questions. ii. Appropriately assess client's strengths, risks and needs. iii. Make recommendations for the management and supervision of the juvenile. iv. Timely evaluation report. f. Target Population: i. All ages, genders, races, abilities, and LGBTQ. g. Language: i. English only. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Services will be provided in one of three (3) office locations: 1. 918 13th Street, #2, Greeley, Colorado 80631 2. 2629 Redwing Road, #140, Fort Collins, Colorado 80526 3. 8811 East Hampden Avenue, #202, Denver, Colorado 80631. Intellectual Disability (ID)/Developmental Disability (DD) Offense Specific Evaluations a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. In -person evaluations using psychological testing if needed. b. Anticipated Frequency of Services: i. Determined on a case by case basis. c. Anticipated Duration of Services: i. Typically completed within a 90 -day period. d. Goals of Services: i. Adult Standards: 1. The purpose of a mental health sex offense -specific evaluation (hereafter evaluation) is to assess a client's need for treatment, determine what type of treatment is needed, and identify the risk level and any additional needs the client may have. 2. Treatment considerations should be based on the conclusions and recommendations of the evaluation. While the evaluation provides valuable information and recommendations, it should be viewed as fluid. As new information emerges, or risk level changes within the course of treatment, a client's treatment should be tailored to address those changes. 3. Because of the importance of the initial information to subsequent sentencing, supervision, treatment, and behavioral monitoring, each client shall receive a thorough assessment and evaluation that examines the interaction between the client's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. 4. Sex offense -specific evaluations are not intended to replace more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner, regardless of the client's status within the criminal justice system. 5. Evaluations recommending sex offense -specific treatment should suggest the use of research informed treatment, management, and monitoring interventions that are appropriate for the risk level, needs, and responsivity of each individual client and that minimize that client's likelihood to sexually reoffend. 6. Consequently, evaluators will prioritize the physical and psychological safety of victims and potential victims in making recommendations that are appropriate to the assessed risk and needs of each client. 7. Various stakeholders, including lawyers, judges, supervising officers, treatment providers and others, rely upon evaluations to make informed decisions at multiple points in time. 8. Evaluators should not assume that readers possess clinical training or expertise in mental health treatment, and should attempt to minimize overemphasis on any single test or aspect of the assessment. 9. Conducted per Standards/Guidelines specific to ID/DD clients. Juvenile Standards: 1. Evaluations are conducted to identify levels of risk and specific risk factors that require attention in treatment and supervision, and to assist the court in determining the most appropriate sentence for juveniles. Due to the importance of the information to subsequent sentencing, supervision, treatment and behavioral monitoring, each juvenile who has committed a sexual offense shall receive a thorough assessment and evaluation that examines the interaction of the juvenile's mental health, social/systemic functioning, family and environmental functioning, and offending behaviors. 2. A thorough review of relevant prior treatment and supervision information can aid in the planning of treatment needs for the client and ensure continuity of care. To this end, it is imperative that the Evaluator make every reasonable effort to identify and obtain past records to determine what treatment may have been completed, what components of treatment need additional focus, and what components of treatment have not yet been completed. 3. Sex offense specific evaluations are not intended to supplant more comprehensive psychological or neuropsychological evaluations. Evaluators have an ethical responsibility to conduct evaluations in a comprehensive and factual manner regardless of the juvenile's status within the criminal justice system. 4. The evaluation ofjuveniles who have committed sexual offenses shall be comprehensive. 5. Recommendations for intervention shall be included in the summary and the evaluation shall be provided in written form to the referring agent. 6. The evaluation ofjuveniles who have committed sexual offenses has the following purposes: A. To assess overall risk to the community; B. To provide protection for victims and potential victims; C. To provide written clinical assessment of a juvenile's strengths, risks and needs; D. To identify and document treatment and developmental/cognitive needs; E. Prior treatment involvement; F. To identify individual differences, potential barriers to treatment, and static and dynamic risk factors; G. To make recommendations for the management and supervision of the juvenile; H. To provide information which can help identify the type and intensity of community based treatment, or the need for a more restrictive setting. 7. Conducted per Standards/Guidelines specific to ID/DD clients. e. Outcomes of Services: i. Answer identified referral questions. ii. Appropriately assess client's strengths, risks and needs. iii. Make recommendations for the management and supervision of the juvenile. iv. Timely evaluation report. f. Target Population: i. All ages, genders, races, abilities, and LGBTQ. g. Language: 4 i. English only. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Services will be provided in one of three (3) office locations: 1. 918 13th Street, #2, Greeley, Colorado 80631 2. 2629 Redwing Road, #140, Fort Collins, Colorado 80526 3. 8811 East Hampden Avenue, #202, Denver, Colorado 80631. Consultation Services a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Record review. ii. Staffing meetings with the Department. b. Anticipated Frequency of Services: i. Determined per case. c. Anticipated Duration of Services: i. Typically within two (2) weeks of services/intake assessment. d. Goals of Services: i. Help determine a referral source for the most cost-effective, evidence based, collaborative, trauma -informed approach to create a treatment plan and/or supervision plan by analyzing a client's case/assesessment. ii. Assist in case review/conceptualization with Department staff via phone calls, emails and all associated parties. iii. Participate in meetings such as staffing's or family meetings via phone or in person. iv. Provide research to the Department if requested. v. Review case records and provide informal risk assessments. vi. Assist Department staff in finding appropriate professionals to help meet treatment needs to mitigate safety concerns and issues that led to child welfare involvement. vii. Help to create an appropriate intervention and/or strategy based upon the risk-need- responsivity (RNR). viii. Provide expert testimony and preparation of summary reports and recommendations. e. Outcomes of Services: i. Answer identified referral questions. f. Target Population: i. All ages, genders, races, abilities, and LGBTQ. g. Language: i. English only. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Services will be provided in one of three (3) office locations: 1. 918 13th Street, #2, Greeley, Colorado 80631 2. 2629 Redwing Road, #140, Fort Collins, Colorado 80526 3. 8811 East Hampden Avenue, #202, Denver, Colorado 80631. LOOK Assessment a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. LOOK Assessment b. Anticipated Frequency of Services: i. Determined per case. c. Anticipated Duration of Services: i. Determined per case. d. Goals of Services: i. Administration of LOOK Assessment compliant with assessment guidelines. ii. Additional administration of assessment if warranted iii. Report outlining results of the assessment. e. Outcomes of Services: i. Determined per case. f. Target Population: i. All ages, genders, races, abilities, and LGBTQ. g. Language: i. English only. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Services will be provided in one of three (3) office locations: 1. 918 13th Street, #2, Greeley, Colorado 80631 2. 2629 Redwing Road, #140, Fort Collins, Colorado 80526 3. 8811 East Hampden Avenue, #202, Denver, Colorado 80631. 5. Cognitive Evaluations a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. In person evaluations using cognitive testing if needed. b. Anticipated Frequency of Services: i. Dependent upon the extent of the evaluation. c. Anticipated Duration of Services: i. Dependent upon the extent of the evaluation, typically 90 days. d. Goals of Services: i. Goals of the service will be determined based on the referral question; Contractor will work with Department to determine the appropriate type of evaluation to answer the referral question. ii. Assess cognitive functioning areas based on referral question, potentially including Intelligence Quotient (IQ), achievement, and adaptive functioning. iii. Recommendations offered based on answers to referral questions. iv. Testing may include: 1. Wechsler Adult Intelligence Scale —Fourth Edition (WAIS-IV) 2. Wechsler Intelligence Scale for Children - Fifth Edition (WISC-V) C1 3. Wide Range Achievement Test Fifth Edition (WRAT-5) 4. Wechsler Individual Achievement Test Third Edition (WIAT-III) 5. Vineland Adaptive Behavior Scales Third Edition (Vineland -3) 6. Social Responsiveness Scale —Second Edition (SRS -2) e. Outcomes of Services: i. Answer identified referral questions. ii. Appropriately assess client's current level of cognitive functioning. iii. Provide clinical insight related to client's level of cognitive functioning. iv. Timely evaluation report. f. Target Population: i. All ages, genders, races, abilities, and LGBTQ. g. Language: i. English only. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Services will be provided in one of three (3) office locations: 1. 918 13th Street, #2, Greeley, Colorado 80631 2. 2629 Redwing Road, #140, Fort Collins, Colorado 80526 3. 8811 East Hampden Avenue, #202, Denver, Colorado 80631. 6. Trauma Evaluations a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. In person evaluations using cognitive testing if needed. b. Anticipated Frequency of Services: i. Dependent upon the extent of the evaluation. c. Anticipated Duration of Services: i. Dependent upon the extent of the evaluation, typically 90 days. d. Goals of Services: i. Goals of the service are determined based on the referral question; Contractor will work with the Department to determine the appropriate type of evaluation to answer the referral question. ii. Assess client's level of trauma and impact of trauma as it relates to the referral question. iii. Recommendations offered based on answers to referral questions. iv. Testing used may include: 1. Minnesota Multiphasic Personality Inventory -2 (MMPI-2) 2. Minnesota Multiphasic Personality Inventory -Adolescent (MMPI-A) 3. Minnesota Multiphasic Personality Inventory -2 -Restructured Form (MMPI-2- RF) 4. Minnesota Multiphasic Personality Inventory- Adolescent -Restructured Form (MMPI-A-RF) 5. Millon Adolescent Clinical Inventory (MACI) 6. Millon Clinical Multiaxial Inventory -IV (MCMI-IV) 7. Trauma Symptom Checklist for Children (TSCC) 8. Trauma Symptom Inventory — Second Edition (TSI-2) 9. Rorschach Test 10. Personality Assessment Inventory (PAI) 11. Personality Assessment Inventory -Adolescent (PAI-A) e. Outcomes of Services: i. Answer identified referral questions. ii. Appropriately assess client's current level of trauma and trauma symptomology. iii. Provide clinical insight related to client's trauma symptomology. iv. Timely evaluation report. f. Target Population: i. All ages, genders, races, abilities, and LGBTQ. g. Language: i. English only. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Services will be provided in one of three (3) office locations: 1. 918 13th Street, #2, Greeley, Colorado 80631 2. 2629 Redwing Road, #140, Fort Collins, Colorado 80526 3. 8811 East Hampden Avenue, #202, Denver, Colorado 80631. Psychological Evaluations (full and partial psychological evaluations) a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: In person evaluations using psychological testing if needed. b. Anticipated Frequency of Services: i. Determined per case. Assessments are typically three (3) to five (5) hours of direct client contact with a psychologist. c. Anticipated Duration of Services: i. Determined per case, typically completed within 90 days. d. Goals of Services: i. Answer questions about a client's psychological variables such as emotional state, personality, pathology, behavior and cognitive/intellectual ability using formal testing, collateral information and clinical judgement. ii. Provide a comprehensive conceptualization (including mental health diagnosis) of the individual that answers the referral question and provides greater insight and clarity into his/her psychological functioning. iii. Provide recommendations that will likely be most effective and efficient in meeting the parent's and/or child's needs. iv. Provide useful information in assessing the strengths and weaknesses of an individual and how these can impact the individual's capacity to parent a child. v. Offer recommendations based on answers to referral questions. e. Outcomes of Services: i. Determined per case. f. Target Population: i. All ages, genders, races, abilities, and LGBTQ. g. Language: i. English only. h. Medicaid Eligibility: i. This service is not Medicaid eligible. i. Service Access and Transportation: i. Services will be provided in one of three (3) office locations: 1. 918 13th Street, #2, Greeley, Colorado 80631 2. 2629 Redwing Road, #140, Fort Collins, Colorado 80526 3. 8811 East Hampden Avenue, #202, Denver, Colorado 80631. Terms 1. Contractor will respond to the Quality Assurance Team (HS-CWOualityAssurance(a weld�ov.com within three (3) business days regarding the ability to accept the received referral. 2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team HS- CWQualityAssurance(a,weldgov.com. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team HS-CWOualityAssurancena,weldgov.com. 4. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team HS-CWOualitvAssu rance(u weldeov.com immediately via email, to discuss service continuation. 5. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 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. 9 Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals will be approved by the caseworker, their supervisor, or the Family Support and Visitation Center. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 9. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Quality Assurance Team, and the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the Client Verification Form. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 10. Contractor will notify the Quality Assurance Team HS-CWOualityAssurance(a�weldaov.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. 10 EXHIBIT D RATE SCHEDULE Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 2022. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Mental Health Services Rate Unit Type Service Name $300.00 Hour Cognitive Evaluation $150.00 Each Consultation Services $150.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $0.57 Mile Mileage, outside the 30 mile radius from provider's three (3) office locations $300.00 Hour Psychological Evaluation $300.00 Hour Trauma Evaluation Sexual Abuse Treatment Rate Unit Type Service Name $150.00 Each Consultation Services $150.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professional Staffing $300.00 Hour Intellectual Disability (ID)/Developmental Disability (DD) Offense Specific Evaluation $300.00 Each LOOK Assessment $0.57 Mile Mileage, outside the 30 mile radius from provider's three (3) office locations $300.00 Hour Offense Specific Evaluation 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 71 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. Entity► Information Entity Namet Entity 113 BRENNA TINDALL PLLC O0043761 ❑ New Entity? Contract Na * Contract 117 BRENNA TINDALL, PLLC (CHILD PROTECTION AGREEMENT) 4858 Contract Status Contract Lead' CTB REVIEW APEGG Contract Lead Email apegg eldgov.com cobbx xlk_ eldgov.com Contract Description* BID# P2100042. TERM: 6/1 i21 -5z 31 /22. Contract Description 2 MEMO WAS PRESENTED TO THE BOCC BY PURCHASING ON 4/7/2021 TYLER ID: 2021-0307. Parent Contract ID 20210307 Requires Board Approval YES Department Project # Contract Type * Department Requested BOCC Aqenda Due Date AGREEMENT HUMAN SERVICES Date* 05/19/2021 00/'23/2021 Amount' Department Email $0.00 CM- Will a work session with BOCC be required?* HumanServices eldgov.co NO Renewable' m YES Does Contract require Purchasing Dept. to be included? Department Head Email Automatic Renewal CM-HumanServtces- DeptHead@weldgov.com Grant County Attorney GENERAL COUNTY IGA ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WELDG O'V.COM 1f this is a renewal enter previous Contract ID 1f this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase : t Effective Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 06:14;2021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 06:21;2021 Originator APEGG Contact Type Review Date 04;01'2022 Committed Delivery Date Contact Email Renewal Date 05:3112022 Expiration Date Contact Phone 1 Contact Phone 2 Purchasing Approved Date 06/14,2021 Finance Approver CONSENT Finance Approved Date 06 14'2021 Tyler Ref # AG 062121 Legal Counsel CONSENT Legal Counsel Approved Date 06' 14 !2021 Hello