The URL can be used to link to this page

Browse Search

Home My WebLink About20192197.tiff/0 /-71--al PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: March 30, 2021 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Protection Agreement Amendments for 2019- 20 Core/Non-Core Contracted Services 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 2019- 20 Core/Non-Core Contracted Services. The Department entered into Agreements with various Child Welfare service providers through the 2019-2020 Request for Proposal (RFP), Bid Number: B1900025, identified as Tyler ID 2019-0707. 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 34 providers reflected in the attached list. Agreements will be renewed for the third and final year for the period of June 1, 2021 through May 31, 2022. 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. Approve Recommendation Perry L. Buck Mike Freeman Scott K. James, Pro-Tem Steve Moreno, Chair Lori Saine Schedule Work Session Other/Comments: Pass -Around Memorandum; March 30, 2021— CMS ID — Various eu.42 (116T) Page 1 -�-i 9-a l 020 /g- 01197 Nt0690 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HEART -CENTERED COUNSELING, INC. DBA LIFESTANCE HEALTH This Agreement Amendment, made and entered into grday of 2021 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human rvices, hereinafter referred to as the "Department", and Heart -Centered Counseling, Inc. DBA LifeStance Health, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Medication Management and Mental Health Services, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2197, approved on June 12, 2019. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement was set to end on May 31, 2020. • The Original Agreement was amended on: December 23, 2019 to amend the Rate Schedule. May 13, 2020 to extend the term date through May 31, 2021 and amend the Rate Schedule. The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2019-2197. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for a third and final year, for the period of June 1, 2021 through May 31, 2022. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST- -dritt/O (I• XY14;t1 BOARD OF COUNTY COMMISSIONERS Weld Clerk to WELD COUNTY, COLORADO By: 4 _ALI Deputy Clerk the Bo teve Moreno, Chair 1►TRACTOR: APR 1 9 2021 Heart -Centered Counseling, Inc. DBA LifeStance Health 1770 25th Avenue, Suite 206 Greeley, Colorado 80634 By: Date: Ylewood (Apr 8, 202118'06 EDT) Melissa Thaxton, Regional Director, Payer Contracting Apr 8, 2021 oZo/9--ou97 Contract Form New Contract Request Entity Information Entity Name* HEART CENTERED COUNSELING INC Entity ID* C4430036411 Contract Name* HEART CENTERED COUNSELING, INC. DBA LIFESTANCE HEALTH (AGREEMENT AMENDMENT) Contract Status CTB REVIEW Contract Description* BID #B1900025. TERM: 6)'1 /21-5/31 Contract Description 2 CONSENT. PA WAS SENT TO CTB ON 3;'31 t21 Contract Type* AMENDMENT Amount* 30.00 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServicesgweldgov.co m Department Head Email CM-HumanServices- DeptHeadgweldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attomey Email CM- COUNTYATTORNEY gWELDG OV,COM ❑ New Entity? Contract ID 4651 Contract Lead* APEGG Contract Lead Email apeggi'lwe ldgov. corn: cobbx xlkgweldgov.corn Requested BOCC Agenda Date* 05; 26!2021 Parent Contract ID 20192197 Requires Board Approval YES Department Project Due Date 05 22 2021 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 04, 01 : 2022 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Committed Delivery Date Contact Type Contact Email Expiration Date* 05; 312022 Contact Phone 1 Contact Phone 2 Purchasing Approver Purchasing Approved Date CONSENT 04 13 2021 Approval Process Department Head JAMIE ULRICH DH Approved Date 04,'13,2021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 04/19;2021 Originator APEGG Finance Approver CONSENT Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 04. 1.3 x' 2021 04 1 3x`2021 Tyler Ref # AG 041921 Coed-r^kax 360 PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: April 2, 2020 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Child Welfare 2020-21 Service Provider Agreement Amendments 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 Welfare 2020-21 Service Provider Agreement Amendments. The Department entered into agreements with various Child Welfare service providers through the 2019-20 Request for Proposal (RFP), identified as Tyler ID 2019-0707). These agreements were issued for a period of three years with the option to renew annually. The attached list reflects the providers, services and rates, including minor rate changes, the Department wishes to enter into for the period of June 1, 2020 through May 31, 2021. 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. Mike Freeman, Chair Scott James Barbara Kirkmeyer Steve Moreno, Pro-Tem Kevin Ross Approve Schedule Recommendation Work Session Other/Comments: Pass -Around Memorandum; April 2, 2020 — Not in CMS Gen-' ��re.•�.o�.. ®5 713/A° Cifi ; S 9 Gtilga6e- ®t`i3/ O Page 1 2m��1-21gT 14-g 0'590 VENDOR RENEWALS Vendor Program Area Service Name Family Therapy -Intake Funding Core Rate $ 69.00 Unit Type Hour Individual Therapy Cora $ 65.00 Hour Individual Therapy, In Home/Community Core $ 95.00 Hour Individual Therapy, In Home/Community-Intake Core $ 95.00 Hour Individual Therapy -Intake Core $ 65.00 Hour Reload -Reboot Educational Learning Opportunities Affecting Direction Core $ 49.00 Hour Reload -Reboot Educational Learning Opportunities ' Affecting Direction, In Home/Community Based Core $ 71.00 Hour Reload -Reboot Educational Learning Opportunities Affecting Direction, In Home/Community Based - Intake Core $ 71.00 Hour Reload -Reboot Educational Learning Opportunities Affecting Direction -Intake Core $ 49.00 Hour Staffing, FTM, TDM, etc. Core $ 30.00 Hour Telebehavioral Health Family Therapy Core $ 69.00 Hour Telebehavioral Health Family Therapy, In Home/Community Based Core $ 101.00 Hour Telebehavioral Health Family Therapy, In Home/Community Based -Intake Core $ 101.00 Hour Telebehavioral Health Family Therapy -Intake Core $ 69.00 Hour Telebehavioral Health Individual Therapy ` Core $ 65.00 Hour Telebehavioral Health Individual Therapy, In Home/Community Based Core $ 95.00 Hour Telebehavioral Health Individual Therapy, In Home/Community Based -Intake - Core $ 95.00 Hour Telebehavioral Health Individual Therapy -Intake Core $ 65.00 Hour Transportation -All Mental Health Services 6 Core $ 0.56 Mile Truancy ASK (Advocate Success for Kids) Core $ 52.00 Hour Truancy ASK (AdvocateSuccess for Kids), In Home/Community Based Core $ 76.00 Hour Truancy ASK (Advocate Success for Kids), In Home/Community Based -Intake Core $ 76.00 Hour Truancy ASK (Advocate Success for Kids) -Intake Core $ 52.00 Hour Truancy ASK -Case Management Services Core $ 30.00 Hour Harmony Acres Equestrian Center Mental Health Services Animal -Assisted Psychotherapy Gore $ 85.00 Hour Heart -Centered Counseling Mental Health Services Medication Management Core $ 68.00 15 Min Medication Management, Assessment` Core $ 158.00 Episode Medication Management, Discount Core $ 100.00 30 min Mental Health Assessment Core $ 100.00 Hour Neu ropsychological Evaluation Core $ 126.00 Hour No Show -Master's Level Session Core $ 85.00 Hour No Show-Ph.D. Level Session Core $ 93.00 Hour Outpatient Psychotherapy, Master's Level Core $ 89.00 Hour Outpatient Psychotherapy, Ph.D. Level Core $ 98.00 Hour IDEA Forum, Inc. Domestic Violence Intervention Anger Management Evaluation CW Block/Child Welfare Services $ 125.00 Episode Domestic Violence Group CW Block/Child Welfare Services $ 35.00 Episode Domestic Violence Intake Evaluation CW Block/Child Welfare Services $ 80.00 Episode WELD COUNTY DEPT. OF HUMAN SERVICES - CHILD WELFARE DIVISION 2020-21 SERVICE VENDORS (CORE/NON-CORE) BID NO.: 82000037 6 c6i„ 1- _TV Ak 36Og AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HEART -CENTERED COUNSELING 411 This Agreement Amendment, made and entered into 13 day of , 2020 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department", and Heart -Centered Counseling, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for, Medication Management and Mental Health Services identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2197, approved on June 12, 2019. 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, 2019. • The Original Agreement was amended on December 23, 2019. The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2019-2197. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for a second full year term, for the period of June 1, 2020 through May 31, 2021. 2. Exhibit D, Rate Schedule, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ,�::.``� -- ,, rr�� -- COUNTY: ATTEST: dd��/tJ �/• �C,�o�� BOARD OF COUNTY COMMISSIONERS Weld unty Clerk to the Board WELD COUNTY, COLORADO B ty Clerk to the Board Mike Freeman, Chair CONTRACTOR; MAY 1 3 2020 Heart -Centered Counseling 1770 25th Avenue, Suite 206 Greeley, CO 80634 By: Date: Dow wewet Doug enger (Apr 2020) Doug Wenger, Director Apr 23, 2020 Coo -7,5e..-14" 05/1g/AC cc H sb O n f�,e1/4grc O.5113t bum 2�1q- 21.37 14Ro©40 EXHIBIT D RATE SCHEDULE 2020-21 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 2021. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Medication Management: $68.00/15 min (Medication Management) $158.00/Episode (Medication Management Evaluation) $100.00/30 min (Medication Management, discount) $85.00/Hour ("No Show" Rate, Master's Level) $93.00/Hour ("No Show" Rate, Ph.D. Level) Mental Health Services: $100.00/Hour (Assessment) $126.00/Hour (Neuropsychological Evaluation) $89.00/Hour (Outpatient Psychotherapy, Master's Level) $98.00/Hour (Outpatient Psychotherapy, Ph.D. Level) $85.00/Hour ("No Show" Rate, Master's Level) $93.00/Hour ("No Show" Rate, Ph.D. Level) 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7`h 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. 1 Contract Form New Contract Request Entity Information Entity Name* Entity ID* HEART CENTERED COUNSELING PC @00036411 Contract Name* HEART CENTERED COUNSELING PC (AGREEMENT AMENDMENT) Contract Status CTB REVIEW ❑ New Entity? Contract ID 3602 Contract Lead* CULLINTA Contract Lead Email cullinta@co.weld.co.us Parent Contract ID Requires Board Approval YES Department Project # Contract Description* CONSENT. BID NO. 6200037. BOCC APPROVAL 04/15/20. CHILD PROTECTION AGREEMENT AMENDMENT. TERM: 06/01/20 THROUGH 05/31(21 FUNDING COREIOTHER. Contract Description 2 Contract Type* AGREEMENT Amount* $0.00 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORN EY@ib'ELD GOV.COM Requested BOCC Agenda Date* 04/1512020 Due Date 04/11(2020 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MCA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On Base Contract Dates Effective Date Review Date* Renewal Date 04/01/2021 Termination Notice Period Committed Delivery Date Expiration Date* 05/31/2021 Contact Information Contact Info Contact Name Purchasing Purchasing Approver Approval Process Department Head JAMIE ULRICH DH Approved Date 05/0512020 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 05/13/2020 Originator SNYDERKL Contact Type Contact Email Finance Approver BARB CONNOLLY Contact Phone I Contact Phone 2 Purchasing Approved Date Finance Approved Date 05/06/2020 Tyler Ref # AG 051320 Legal Counsel GABE KALOUSEK Legal Counsel Approved Date 05/06/2020 Submit e.entraCi- =o #$'3a3g PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: November 19, 2019 TO: Board of County Commissioners — Pass -Around FR: Judy A. Griego, Director, Human Services RE: Agreement Amendment to Heart -Centered Counseling Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Agreement Amendment with Heart -Centered Counseling. The Department entered into an agreement with Heart -Centered Counseling for Outpatient Mental Health Counseling, Psychological Testing, and Medication Management, identified as Tyler ID 2019-2197, on June 12, 2019, for the term of June 1, 2019 -May 31, 2020. The vendor has requested to add the following rates for the following services: Medication Management: - $85.00/Hour ("No Show" Rate, Master's Level) - $93.00/Hour ("No Show" Rate, Ph.D. Level) Mental Health Services: - $85.00/Hour ("No Show" Rate, Master's Level) - $93.00/Hour ("No Show" Rate, Ph.D. Level) I do not recommend a Work Session. I recommend approval of the Agreement Amendment. Sean P. Conway Mike Freeman, Pro-Tem Scott K. James Barbara Kirkmeyer, Chair Steve Moreno Approve Schedule Recommendation Work Session �941 Pass -Around Memorandum; November 19, 2019 - CMS 3238 Other/Comments: n Alt/ Z(P.D) Page 1 c20/9-01/97 ,moo b 90 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HEART -CENTERED COUNSELING This Agreement Amendment, made and entered into du... day of 2019, by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department", and Heart -Centered Counseling, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Outpatient Mental Health Counseling, Psychological Testing, and Medication Management, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2197, approved on June 12, 2019. 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, 2020. • 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. Exhibit D, Rate Schedule, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. ATTES Weld By ,dgerAdiv &4C COUNTY: BOARD OF COUNTY COMMISSIONERS lerk to the Boar W; LD COUNTY, CC}LORADO • eputy Clerk arbara Kirkrlleyer, Chair CONTRACTOR: Heart -Centered Counseling 323 East 27th Street Loveland, CO 80538 By: Date: et Doug nger(Nov 2019) Doug Wenger, Director Nov 11, 2019 DEC t 3 nig 02oi9-.2-/ f EXHIBIT D RATE SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 2020. 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 Medication Management: $65.00/15 min (Medication Management) $150.00/Episode (Medication Management Evaluation) $95.00/30 min (Medication Management, discount) $85.00/Hour ("No Show" Rate, Master's Level) $93.00/Hour ("No Show" Rate, Ph.D. Level) Mental Health Services: $95.00/Hour (Assessment) $120.00/Hour (Neuropsychological Evaluation) $85.00/Hour (Outpatient Psychotherapy, Master's Level) $93.00/Hour (Outpatient Psychotherapy, Ph.D. Level) $85.00/Hour ("No Show" Rate, Master's Level) $93.00/Hour ("No Show" Rate, Ph.D. Level) 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the Th 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. 1 Contract Farm New Contract Request Entity Information Entity Name* Entity ID* HEART CENTERED COUNSELING PC @0©036411 ❑ New Entity? Contract Name* Contract ID HEART CENTERED COUNSELING PC (AGREEMENT 3238 AMENDMENT) Contract Status CTB REVIEW Contract Lead* CULLINTA Contract Lead Email cullinta a@co weld.co us Parent Contract ID 26192197 Requires Board Approval YES Department Project # Contract Description* AGREEMENT AMENDMENT TO EXISTING CHILD PROTECTION AGREEMENT FOR SERVICES TO ADD NO-SHOW RATES. Contract Description 2 Contract Type " AGREEMENT Amount "k $0.00 Renewable* NO Automatic Renewal Grant Department HUMAN SERVICES Department Email CM- HumanSery ces@weldgov.com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYA I I ORN EY@WELD GOV.COM Requested BOCCC Agenda Date* 11120;2019 Due Date 11/1612019 Will a work session with BDCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On Base Contract Dates Effective Date Review Date* Renewal Date 04/01.2020 Termination Notice Period Committed Delivery Date Expiration Date 05(31 12020 Contact Information Contact Info Contact Naive Purchasing hasing Approver Approval Process Department Head JUDY GRIEGO DH Approved [late 12/10/2019 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date Originator SNYDERKL Contact Type Contact Email Finance Approver BARB CONNOLLY Contact Phone 1 Contact Phone 2 Purchasing Approved Date Finance Approved slate 12112/2019 Tyler Ref Legal Counsel KARIN MCDOUGAL Legal Counsel Approved Date 1211712019 Submit , CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND HEART -CENT /7D COUNSELING This Agreement, made and entered into the,(ZGday of 019, by and between the Board of Weld County Commissioners, on behalf of the Weld County Departme of Human Services, hereinafter referred to as the "Department' and Heart -Centered Counseling, hereinafter referred to as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule. Exhibit B, C, and D are attached hereto and incorporated herein by this reference. Exhibit A is Weld County's Request for Proposal Number B1900025, 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 Medication Management and Mental Health Services. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 2019, upon proper execution of this Agreement and shall expire May 31, 2020, unless sooner terminated as provided herein. The agreement is for a period of three years. However, the agreement must be renewed by both parties, in writing, on an annual basis. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit B, Contractor's Response to Request for Proposal and Exhibit C, Scope of Services. 3. Referrals, Billing and Tracking a. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e- mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Quality Assurance Team Supervisor (hainleld@weldgov.com, 970-400-6210). No other Department staff or other party to the case may authorize services or modifications to services. c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation by the 7t'' of the month, following the month of service, utilizing billing forms required by the ,6: Oxie)-0-2-e-04-5D) 2019-2197 7/1-koo9a Department. Contractor agrees to utilize the Client Verification Form for all scheduled and unscheduled face-to-face services with the exception of home studies and monitored sobriety testing. Contractor agrees that original complete Client Verification Forms are to be submitted with the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet 60 -day deadline may result in termination of the Agreement. d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service, for each client receiving ongoing services. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Date and time of service b. Where the service took place c. Clinician/therapist name d. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will be the test result. A completed home study may be a full, partial or denied study, as determined by the Department. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. 4. Payment a. The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: i. The service being provided by the contractor is not a Medicaid eligible service; ii. The service is not deemed medically necessary; iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; iv. A Medicaid provider is not available to provide the needed service; v. Medicaid is exhausted for the needed service; or vi. Medicaid denied service. vii. The client is not eligible for Medicaid. b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule, attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent upon, the continuing availability of said funds for the purposes hereof. 2 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 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 an, which will be provided by the Department, with a voided check. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and Title VII of the Civil Rights Act of 1964; and 3 the Age Discrimination in Employment Act of 1967; and the Equal Pay Act of 1963; and the Education Amendments of 1972; and - Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and - all regulations applicable to these laws prohibiting discrimination because of race, color, national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, Contractor and the Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any all Federal and/or State financial assistance. - Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, contractors and sub -contractors. b. Contractor is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the United States Department of Health and Human Services, Office for Civil Rights. c. Contractor assures that it will fully comply with all other applicable Federal and State laws which may govern the ability of the Department to comply with the relevant funding requirements. Contractor understands the source of funds to be accessed under the Agreement is determined by the Department. d. Contractor assures and certifies that it and its principals: - Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a Federal or State department or agency; and - have not, within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; and - are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state or local) with commission of any of the offenses enumerated in this certification; and - have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, or local) terminated for cause or default. 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 4 contract. Contractor will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E -Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5- 102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to undertake pre -employment screening or job applicants while this Agreement is being performed. If Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contractor shall not terminate the contract if within three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. shall comply with reasonable requests made in the course of an investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and Employment. If Contractor participates in the State of Colorado program, Contractor shall, within twenty days after hiring a new employee to perform work under the contract, affirm that Contractor has examined the legal work status of such employee, retained file copies of the documents, and not altered or falsified the identification documents for such employees. Contractor shall deliver to the Department, a written notarized affirmation that it has examined the legal work status of such employee and shall comply with all of the other requirements of the State of Colorado program. If Contractor fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq., the Department, may terminate this Agreement for breach, and if so terminated, Contractor shall be liable for actual and consequential damages. f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if Contractor receives federal or state funds under the contract, Contractor must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the contract. If Contractor operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24- 76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. § 24-76.5- 103 prior to the effective date of the contract. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR) and will address the aforementioned three areas when completing monthly reports as required by Paragraph 3(d) of this Agreement. 5 9. Insurance Requirements Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, its 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, the following insurance coverage. Weld County, State of Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible the insurance provider. 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 0110/93 or equivalent, covering premises operations, fire damage, independent Contractors, 6 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 as follows f. Waiver of Subrogation: For all coverages, Contractor's insurer shall waive subrogation rights against County. g. Subcontractors: All subcontractors, independent contractors, sub -vendors, suppliers or other entities providing goods or services required by this Agreement shall be subject to all of the requirements herein and shall procure and maintain the same coverages required of Contractor. Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers or other entities as insureds under its policies or shall ensure that all subcontractors maintain the required coverages. Contractor agrees to provide proof of insurance for all such subcontractors, independent contractors, sub -vendors, suppliers or other entities upon request by the Department. A provider of Professional Services (as defined in the Bid or RFP) shall provide the following coverage: Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and $2,000,000 aggregate limit for all claims. 10. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-400-6503 and advise that the subpoena must be personally served. 13. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any 8 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 Doug Wenger, Director 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: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970)400-6510 9 For Contractor: Doug Wenger, Director 323 East 27`h Street Loveland, CO 80538 003) 361-7093 18. Litigation Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department, or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third -Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties/Conflict of Interest No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department when the Contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the two relationships are in opposition. During the term of the Agreement, Contractor shall 10 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 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. 11 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, and as set forth in Exhibit A provide proof thereof when requested to do so by County. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work, nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner consistent with the professional standards governing such services and the provisions of this Agreement. The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence and judgment provided by highly competent individuals and entities that perform services of a similar nature to those described in this Agreement including Exhibits A, 8, C, and D. 12 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to the Department originals of all tests and results, reports, etc., generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. §§24-18-201 et seq. and §24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 34. Choice of Law/Jurisdiction Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 13 36. Attorney's Fees/Legal Costs In the event of a dispute between the Department and Contractor, concerning this Agreement, the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf. 37. Ownership All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of the Department. In addition, all reports, documents, 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. 14 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY:. ATTEST: dalf411) v• Jeito4 BOARD OF COUNTY COMMISSIONERS Weld Co y Clerk to the Board _ WELD COUNTY, COLORADO By: Deputy Clerk to e Boa d 15 rbara Kirkmeyer, Ch 142 2. CONTRACTOR: Heart -Centered Counseling 323 East 27th Street Loveland, CO 80538 (603)361-7093 By: Date: Ooh 211 er (Apr 23, 2019) Doug Wenger, Director Apr 23, 2019 O019- x197 EXHIBIT A WELD COUNTY'S REQUEST FOR PROPOSAL (Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon request to the Department.) This page intentionally left blank. EXHIBIT B CONTRACTOR'S RESPONSE TO REQUEST FOR PROPOSAL Heart -Centered Counseling Weld County Department of Human Services Bid Introduction Letter: Heart -Centered Counseling is seeking to partner with Weld County DHS to offer behavioral health services, including counseling and medication management services. Heart -Centered Counseling is one of Larimer and Weld County's largest outpatient mental health groups. We now have about 126 therapists and thousands (1,000+) of different clients seen each week. We have added eight med providers to our staff as well. Heart -Centered Counseling now has 14 office locations, three in Weld County (located in the city of Greeley) and seven in Larimer County, three in Loveland and four in Fort Collins. We also have offices in Littleton, Castle Rock and Denver. Our group continues to grow to meet the demand of the community, our clients and our referral sources, providing quality and timely care to those in need. Heart -Centered Counseling makes the following commitments to the communities it serves in an effort to be able to meet the community's mental health needs, to be responsive to client's needs and be able to quickly get clients scheduled for services that they need: 1. Immediate Availability: We understand that when individuals or referring agencies call for Mental Health support, the need is almost always immediate. For this reason, whenever a client needs to be seen quickly, we get over 90% of our clients scheduled for appointments scheduled within 7 days. 2. Acceptance of Medicaid, Medicare, and all Commercial Insurances: We accept all major insurances, including Medicaid, Medicare, and private commercial insurance plans such as those offered through BC/BS, United, Cigna, Beacon, Tricare, Aetna, Kaiser and so on, as well as a number of EAP programs including Mines and Associates, Morneau Shepell and more. 3. Coverage for all areas of Behavioral Health: We work with children as young as 1 and adults of all ages, including the elderly, couples, and families. We offer support for the wide spectrum of mental health issues, ranging from trauma, to substance abuse, to anxiety and depression, to eating disorders, to you -name -it. And we have therapists that deliver a wide variety of modalities and specialties, including EMDR, accu detox, and neuro feedback. 4. Experienced Care: A large percentage of our therapists have over 10 years of experience, and many have over 30. We pride ourselves in offering experienced clinical care and have an in-house training program that covers ethics and ongoing clinical training to ensure our therapists remain both experienced and engaged. 5. Coordination of Care: We provide a weekly report on any new referrals, letting you find out what happened when we reached your client to schedule an appointment. We also offer monthly treatment updates which share information such as frequency of visits and progress in therapy. 6. We have added more Nurse Practitioners to allow us to better serve the needs of our community in terms of medication management. EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Heart Centered Counsehrg AGENCY OR PRIVATE PRACTICE -RAL.S PROVIDER ID (If Known) Doug Wenger Director PRIMARY CONTACT - FULL NAME PRIMARY CONTACT - TITLE (603) 3617093 (888( 965 4615 PHONE NUMBER EXT FAX NUMBER OouPLilhearTrenteredcounselors nom h;to //heartcenleredcounselon coin. PRIMARY CONTACT- E-MAIL ADDRESS AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) 323 E 27th St AGENCY MAILING ADDRESS Lovelanc 80538 CITY ZIP REFERRAL CONTACT Ginger K,ein and A, Mannino FCT Director and ECT Assistant Director REFFERAI. CONTACT - FULL NAME REFERRAL CONTACT - TITLE 970-310-3406 gingerkgeheartcenteredcounselors cam annma@hearteenteredcaunselors com REFERRAL CONTACT PHONE NUMBER EXr RE=ERRAL CONTACT - E-MAIL ADDRESS Carla Amon to BILLING CONTACT &LUNG CONTACT - FULL NAME 1970; 372.6625 B'. LONG CONTACT— PHONE NUMBER EMT InsLrance Team Director BILLING CONTACT - TITLE msurerreteaml�hrartcenteredcounselurs cum BILLING CONTACT — E-MAIL ADDRESS I certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the 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. 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'. Signature of Authorized Representative: Date of Signature: //-7 /- / T r Bid No.: B 1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: 2. Program name or service type being proposed: Heart Centered Counseling Outpatient Mental Health Counseling, Psychological Testing and Medication Management. 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Outpatient Psychotherapy for MH and SUD Issues that Includes: • Individual Therapy, Utilizing a combination of: o Cognitive Behavioral Therapy (CBT) o Motivational Interviewing o Person Centered Therapy o EMDR o Trauma Focused — Cognitive Behavioral Therapy TF-CBT o Dialectical Behavioral Therapy o Play Therapy o Acceptance and Commitment Therapy o Harm Reduction o Gottman o Narrative Therapy • Couples o Emotionally Focused Therapy o Gottman • Family Therapy • Group Therapy o Dialectical Behavioral Therapy o Seeking Strength/Safety Assessments • Diagnostic psychological assessment -ADHD assessment • Learning Disability assessment -Autism assessment; • Substance use disorder evaluations -neuro-psych evaluations Medication Management Services • Initial medication evaluations • Ongoing medication management services Neuro-Psychological Testing/Evaluations • Administer psychological evaluations/testing • Interpretation of psychological evaluations/testing 4. Capacity to Provide Services (ex. 4 hours/week). • Our offices see clients as early as 7:30am and as late as 8pm Monday - Friday. Some weekend availability is offered, on Saturdays. We currently have 126 therapists, 8 nurse practitioners and thousands (1,000+) of different clients seen each week. Heart -Centered Counseling now has 14 office locations, three in Weld County (located in the city of Greeley) and seven in Larimer County, with three in Loveland and four in Fort Collins. We also have offices in Littleton, Castle Rock and Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE Denver. Our group continues to grow to meet the demand of the community, our clients and our referral sources, providing quality and timely care to those in need. 5. Goals of the service. • Our primary goal at Heart Centered Counseling is to help all individuals recover from mental health and substance use disorder issues. We strive to offer the best care and provide people with long lasting change. We are a trauma informed practice group. We recognize the impact trauma has on individuals and how this can shape their mental health and substance use disorder issues. We offer clients therapy that meets their needs to help them recover from and heal trauma. • Immediate Availability: We understand that when individuals or referring agencies call for Mental Health support, the need is almost always immediate. For this reason, whenever a client needs to be seen quickly, we get 90% of our clients scheduled within one week. 6. Outcomes of service. • At Heart Centered Counseling we are committed to providing excellent mental health and substance use disorder treatment. This is evidenced by the fact that 89% of the time our client's return after the first session. • Our commitment to excellence starts at the first phone call from the client. Over 90% of the time we are able to offer a client their initial appointment within 7 days. • It is routine HCC clinical practice to offer its clients at least 4 appointments within 45 days of the first session but we have not tracked this data point specifically. HCC therapists typically schedule one appointment per week for clients early in the therapeutic process. However, not all clients are able or interested to meet this frequently. If requested by Weld DHS, we will track this performance indicator for CORE referrals. • We offer ongoing clinical supervision and consultation for all of our therapists in order to help our clinicians hone their therapeutic skills in order to best serve our clients. 7. Target population for service. Note: Please include age range, applicable genders, and any specific characteristics/traits/needs. • Young Children • Adolescents • Adults (young, middle-aged, and elderly) — Couples • Families 8. Service access. Note: Bidder must indicate capacity for video conferencing, phone conferencing and in person. If office -based, bidder should provide full physical addresses for all locations. If provided outside the office, bidder should note home -based and/or community -based, and geographical area(s) bidder is willing to travel to. • We offer in person psychotherapy and medication management. With locations in Greeley, Loveland, and Fort Collins. o Our Greeley Offices are located at: ■ 1770 25th Ave Suite 206 ■ 1770 25th Ave Suite 202 1013 37th Ave Ct Suite 101 o Our Loveland Offices are located at: Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE • 1032 N Lincoln Ave ■ 1413 W 29th St ■ 323 East 27th St o Our Fort Collins Offices are located at: • 320 W Olive St • 1525 Riverside Ave ■ 1531 Riverside Ave • 1537 Riverside Ave ❑ Our Littleton Office are located at: • 5911 S Middlefield Rd, Suite 100 ■ 5911 S. Middlefield Rd, Suite 200 ❑ Our Denver Office is located at: • 950 E Harvard Ave, Suite 670 ❑ Our Castle Rock Office is located at: • 410 S. Wilcox Street • We also offer tele therapy and medication management through secure video conferencing. We have partnered with various doctors' offices in communities to offer integrated tele therapy to help individuals located in rural areas where broadband may not be as accessible. 9. Languages service is available in. Note: Bidder should note the language and level of proficiency. • Proficiency in English and Spanish. 10. Rates of Service. Note: Bidder should include fee for service, staffing, mileage, and any other applicable costs bidder would like considered. Rates must be an exact amount and must include the unit of cost (i.e., hour, day, month, episode). Approximate rates or a range of rates for a service will not be accepted. • Outpatient Psychotherapy - Master's Level practitioner $85 per hour, Ph.D. Level practitioner $93 per hour. • Assessment - $95 per hour. Duration of any assessment can be discussed on a case -by -case basis prior to the start of any work. • Medication Management - $150 for initial Medication Evaluation appointment; $95 for 30min medication management; $65 for 15min medication management. • Neuro-Psychological Evaluations - $120 per hour. Bid No.: 1900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeEk441BJlE® One Staff Data Sheet per proposed service. Bidder should not combine services.) PROPOSED SERVICE OR SERVICE TYPE: Outpatient Mental Health Counseling, Psychological Testing and Medication Management. BIDDER LEGAL ENTITY NAME: Heart Centered Counseling APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION No. Last Name First Name Workp Work Email Education Level Degree Focus Ucensure/ Credentials DORA it (If applicable) 1 Alieksaites Jodi 720-295-1845 jodi@heartcenteredcounselors.com Masters of Arts LPC LPC. 0013030 2 Bagwell Stephanie 720-507-7686 stephanie@heartcenteredcounselors.com Doctor of Psychology Psy PSY. 0004599 3 Baker Elissa 970-371-8911 elissa@heartcenteredcounselors.com Masters of Arts LPC LPC. 0005535 4 Barou Daniela 970-426-0452 danielab@heartcenteredcounselors.com MasterofSocial Work LCSW CSW. 09924910 5 Barr Thomas 303-664-5281 tom@heartcenteredcounselors.com Doctor of Psychology Ph.D PSY.0002160 6 Beals Dena 970-414-0656 denab@heartcenteredcounselors.com Masters of Arts LMFT MFT. 0001561 7 Blocksma Douglas 970-414-0210 douglas@heartcenteredcounselors.com Bachelor of Science LPC LPC. 0012484 8 Bolint Susan 970-829-8804 sue@heartcenteredcounselors.com Masters of Arts LMFT, LAC MFT. 0001049 9 Bomberg Ann 720-442-4506 annieb@heartcenteredcounselors.com Master of Social Work LCSW CSW.00993043 10 Boyer Tammy 970-449-3431 tammy@heartcenteredcounselors.com Master of Social Work LCSW CSW.00002092 11 Burnett Jennifer 970-324-4976 jen@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW. 09923444 12 Burton John 970-939-4488 johnb@heartcenteredcounselors.com Doctor of Education LPC, EdD LPC. 0015153 13 Castillo Jamie 970-541-9307 jamie@heartcenteredcounselors.com Masters of Arts LPC LPC. 0013275 14 Chavez Cynthia 970-584-6365 cynthia@heartcenteredcounselors.com Masters of Arts LPC,MA,CACII LPC. 0014138 15 Collinsworth Cindy 720-504-7387 cindyc@heartcenteredcounselors.com Masters of Arts LPC LPC. 0012492 16 Conner Abbie 970-460-8019 abbie@heartcenteredcounselors.com Master of Social Work LCSW CSW.09923028 17 Cowan Krista 970-381-3388 kristac@heartcenteredcounselors.com Masters of Arts LPC, LAC ACD. 0000430 18 Davis Alyssa 970-402-6238 alyssadavis@heartcenteredcounselors.com Masters of Arts LPC LPC. 0013522 19 De la Torre Alyssa 970-305-4101 ayssa@heartcenteredcounselors.com Masters of Arts LPC LPC. 0014051 20 Diamond Carole 970-581-3802 caroled@heartcenteredcounselors.com Masters of Arts PMHNP-BC, NP -C RN. 0130431 21 Dimmen-Klenk Amanda 970-400-1953 amanda@heartcenteredcounselors.com Master of Science LMFT MFT. 0001447 22 Edsall Deborah 970-590-0590 deborahe@heartcenteredcounselors.com Doctor of Science LPC LPC. 0003229 23 Edwards Janis 970-617-5990 janise@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW. 09924789 24 Eells Stephanie 720-254-0494 shephaniee@heartcentercounselors.com Master of science LPC, DBTC LPC.0001245 25 Engelman Blake 970-829-8732 blake@heartcenteredcounselors.com Licensed Professional Coun LPC LPC. 0013480 26 Falcao Genesa 720-582-3570 genesa@heartcenteredcounselors.com Masters of Arts LPC LPC. 0012470 27 Flint Velvet 719-691-9765 velvetf@heartcenteredcounselors.com Master of science LPC LPC. 0011809 28 Flores Denise 805-798-1370 denise@heartcenteredcounselors.com Master of Science LMFT MFT. 0001465 Bid No.: B1900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeFM4tl81iE(0 One Staff Data Sheet per proposed service. Bidder should not combine services.) 29 Foley Suzanne 970-344-9905 suzanne@heartcenteredcounselors.com Masters of Arts LPC LPC. 0012508 30 Ford Haley 978-709-1309 haley@heartcenteredcounselors.com Doctor of Philosophy Ph.D PSY. 0004641 31 Friese Ariel 312-952-7901 ariel@heartcenteredcounselors.com Master in Counseling LPC LPC.0011347 32 Garcia Monica 925-337-0415 monica@heartcenteredcounselors.com Doctor of Psychology Psy.D PSY. 0004741 33 Gardner Lawrence 804-869-5981 lee@heartcenteredcounselors.com Master of Social Work LCSW CSW.09925369 34 Gastel Rosalyn 909-379-4700 rosalyng@heartcenteredcounselors.com MasterofSocial Work LCSW CSW. 09925434 35 Gentry Deborah 281-961-7838 debbie@heartcenteredcounselors.com MasterofSocial Work LCSW CSW. 09924057 36 Gills Gina 720-318-8866 ginag@heartcenteredcounselors.com MasterofSocial Work LCSW CSW. 00001221 37 Graber Justine 720-509-9869 justineg@heartcenteredcounselors.com Masters of Arts LPC, LMFT, LAC MFT. 0001294 38 Green Sarah 970-373-5246 sarahg@heartcenteredcounselors.com Master of Social Work LCSW CSW.09925660 39 Grossman Joseph 970-301-1089 joe@heartcenteredcounselors.com Masters of Arts LPC LPC. 0013556 40 Hand Amanda 970-795-2144 amandah@heartcenteredcounselors.com Masters of Arts MNM, LPC LPC. 0003930 41 Healy Amy 970-612-8588 amy@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW. 09925162 42 Hedrick Jami 720-772-0592 jamih@heartcenteredcounselors.com Master in Counseling LPC LPC.0006110 43 Herom Pedar 970-579-0634 pedarh@heartcenteredcounselors.com Masters of Arts LPC LPC. 0014313 44 Herrick Pamela 949-680-7878 pamelah@heartcenteredcounselors.com Masters of Arts LMFT MFT. 0001552 45 Hessel Laurie 970-214-2834 laurieh@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW. 00989158 46 Hotchkiss Roxanne 720-924-6615 roxanneh@heartcenteredcounselors.com Master of Social Work LCSW CSW.09923625 47 Huemmler Johanna 970-795-2825 jojoh@heartcenteredcounselors.com Master of Science LMFT MFT. 0001450 48 Inglis Sharon 720-257-9212 sharoni@heartcenteredcounselors.com Masters of Arts LCSW CSW.00000781 491zmirian Sonia 608-561-1576 soniai@heartcenteredcounselors.com Doctor of Philosophy Ph.O PSY.0004874 50 Jansen Kristin 970-599-1405 kristinj@heartcenteredcounselors.com Masters of Arts LPC, LAC LPC. 0002745 51 Jones Cheyenne 970-673-7869 cheyennej@heartcenteredcounselors.com Master in Counseling LPC LPC. 0014925 52 Kipp Ginger 720-316-7482 gingerk@heartcenteredcounselors.com Masters of Arts LPC LPC.0002132 53 Kraemer Sharlene 941-524-0842 cheryk@heartcenteredcounselors.com Masters of Science in educe LPC LPC.0013471 54 Le Pont -Fowler Jennifer 970-430-6113 jenniferl@heartcenteredcounselors.com Psychiatric/Mental Health DNP APN. 0993608 55 Leaderman Alexandra 415-940-1428 alexandra@heartcenteredcounselors.com Master in Counseling LPC LPC. 0014269 56 Lohse Lauri 970-660-8098 lauri@heartcenteredcounselors.com Registered Nurse ARNP RN.1655161 57 Lutz James 303-653-6901 jim@heartcenteredcounselors.com Masters of Arts Ed.D.,LPC LPC. 0012648 58 Mavrides Gregory 970-617-4020 greg@heartcenteredcounselors.com Doctor of Philosophy PhD CSW. 09925008 59 McDonald Emily 970-834-3699 emilym@heartcenteredcounselors.com Masters of Arts LPC LPC. 0013862 60 McDonell Rena 970-658-8899 rena@heartcenteredcounselors.com Masters of Science LPC LPC.0013582 61 McGuire Terry 720-432-7553 terrym@heartcenteredcounselors.com Master of Social Work LCSW CSW.00991055 Bid No.: 81900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposePMim&TE® One Staff Data Sheet per proposed service. Bidder should not combine services.) 62 Meisinger Tracy 970-581-0980 tracym@heartcenteredcounselors.com Master in Counseling MFT, LPC, NCC LPC.0015101 63 Morse Angelica 720-446-6659 angelica@heartcenteredcounselors.com Master of Social Work LCSW CSW.09923929 64 Musial Stacy 970-236-1866 stacy@heartcenteredcounselors.com Master of Social Work MSW,LCSW CSW. 09923929 65 Nabers Lance 512-578-5283 lancen@heartcenteredcounselors.com Master of Science LPC LPC. 0013506 66 Neves Hali 307-272-1132 hali@heartcenteredcounselors.com Masters of Arts LPC LPC. 0014207 67 Oxton Adrian 218-329-1762 adrian@heartcenteredcounselors.com Masters of Arts LPC, LAC LPC. 0011495 68 Paroz Natala 505-401-2199 natala@heartcenteredcounselors.com Master of Social Work Masters of Arts MSW, LCSW CSW.09924711 69 Pike Molly 720-863-6373 mollyp@heartcenteredcounselors.com LPC LPC. 0013686 70 Popescu Cezar 632-693-4921 cezarp@heartcenteredcounselors.com Masters of Arts LPC LPC.0014341 71 Preston Mary 970-541-9534 mary@heartcenteredcounselors.com Masters of Arts LMFT MFT. 0001310 72 Preston Nathan 808-282-8323 nathan@heartcenteredcounselors.com Masters of Arts LMFT MFT. 0001302 73 Price Kathryn 720-695-1414 kathryn@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW.09923689 74 Pucciarello Andrea 303-524-0050 andrea@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW. 00001128 75 Rauls Charity 720-507-4543 charityr@heartcenteredcounselors.com Masters of Arts LPC LPC. 0014151 76 Reid Laura 970-573-7593 Laura@heartcenteredcounselors.com MasterofSocial Work LCSW CSW. 09924105 77 Reisen Mira 970-400-1432 mirar@heartcenteredcounselors.com Master of Science LMFT MFT. 0001533 78 Kershner-Rice Kendall 303-332-7752 kendallr@heartcenteredcounselors.com Doctor of Philosophy Ph.D PSY. 0004886 79 Rogers Adrienne 970-823-2875 adrienner@heartcenteredcounselors.com Masterof Social Work LCSW CSW. 09925436 80 Roney Christopher 217-649-8719 chrisr@heartcenteredcounselors.com Masterofsocial Work LCSW CSW. 09924221 81 Ross Dalton 720-819-6354 daltonr@heartcenteredcounselors.com jayr@heartcenteredcounselors.com MasterofSocial Work LCSW CSW. 00000151 82 Ryser Jay 720-443-2791 Master in Counseling MEd, LPC LPC.0002457 83 Schwintosky Brittani 720-432-5587 brittani@heartcenteredcounselors.com Master of Science in Nursln APN 0000783 C -NP 84 Scofield Mark 970-683-0775 mark@heartcenteredcounselors.com Master of social Work LCSW LCSW.991945 85 Sehr David 970-310-3406 davids@heartcenteredcounselors.com Doctor of Medicine Masters of Arts MD DR.0048058 86 Shelstad Brody 720-625-0747 brodys@heartcenteredcounselors.com LMFT MFT.0001582 87 Shirk Kimberly 970-880-1429 kims@heartcenteredcounselors.com Masters of Arts LPC, NCC LPC.0014091 88 Stanley Lauren 832-725-3636 laurens@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW.09924274 89 Stillman Melissa 954-254-3760 melissas@heartcenteredcounselors.com Master of Science and Educ Masters of Arts M.S.Ed., LPC LPC.0013200 90 Stuart Tracy 720-947-9590 tracys@heartcenteredcounselors.com LPC LPC.0012188 91 Talarico Linda 908-472-0943 lindatalarico@heartcenteredcounselors.com Clinical Social Worker LCSW CSW.09925185 92 Thompson Marcella 530-949-5162 marcellat@heartcenteredcounselors.com Master of Social Work LCSW CSW.09925635 93 Torvik Molly 970-372-4456 molly@heartcenteredcounselors.com abbeyt@heartcenteredcounselors.com Master of science MSN, FNP-C APN.0993750-NP 94 Towe Abigail 970-364-6177 Master of Science in Nursin MSN, FPMHNP- BC C-APN.0001182 Bid No.: 81900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposed(4m&tE0 One Staff Data Sheet per proposed service. Bidder should not combine services.) 95 VanderBeek Christina 970-310-8876 Christina@heartcenteredcounselors.com Masters of Arts LPC LPC.0013638 96 VanDerWerff Jay 970-460-6219 jay@heartcenteredcounselors.com Master of Social Work LCSW, LAC ACD.0000765 97 Voelsing Kathleen 970-302-3434 KathleenV@heartcenteredcounselors.com Other Degree PMHNP-BC, DNP APN.0990685-NP 98 VoVillia Jeffery 303-847-9172 jeff@heartcenteredcounselors.com Masters of Arts LPC LPC.0012765 99 Walk Caitlin 970-699-5277 caitlin@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW.09925112 100 Watt Kathryn 970-880-1654 katyw@heartcenteredcounselors.com Masters of Arts LPC LPCC.0014880 101 Weitzel Michael 970-420-2586 mkhael@heartcenteredcounselors.com Masters of Arts LPC LPC.0005152 102 Wells Cindy 720-989-5695 cindywells@heartcenteredcounselors.com Master of Science LPC LPC.0002616 103 Wenger Douglas 603-361-7093 doug@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW.09923897 104 White Angela 970-829-8568 angela@heartcenteredcounselors.com kenw@heartcenteredcounselors.com Master in counseling LPC,CACIII ACB.0008153 105 Whitney Ken 720-900-2106 Master of Social Work MSW, LCSW CSW.00993005 106 Wilson Rebecca 720-739-0639 rebecca@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW.00001376 107 Wilson Thomas 970-930-1264 thomasw@heartcenteredcounselors.com Master of Social Work MSW, LCSW CSW.09925447 108 Woods Allison 720-979-7725 allison@heartcenteredcounselors.com Licensed of Professional Co LPC LPC.0006336 109 Woods LeAnn 928-451-1780 leann@heartcenteredcounselors.com Masters of Arts LPC LPC.0013282 110 Wooldridge Susan 802-760-7946 susanw@heartcenteredcounselors.com Bachelor of Arts LPC LPC.0014424 111 Wurst Amanda 303-325-4047 amandaw@heartcenteredcounselors,com Master of Social Work MSW, LCSW CSW.00001505 Bid No.: 81900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeFM4m81i ID One Staff Data Sheet per proposed service. Bidder should not combine services.) Bid No.: 81900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeaft184fE® One Staff Data Sheet per proposed service. Bidder should not combine services.) SUPERVISES CAN°IDATE/INTERN INFORMATION last Name First Nam Work # Work Email Education Level Degree Focus Licensure/ Credentials DORA # (If applicable) Ball Caleb 970-829-8879 calebb@heartcenteredcounselors.com MA LPCC LPCC.0015197 Benz Jonathan 260-460-7786 jonathan@heartcenteredcounselors.com MA LPCC LPCC.0015274 Chabrier Joel 480-272-0543 joelc@heartcenteredcounselors.com MA LPCC LPCC.0016220 Dauk Nadara 970-541-9678 nadarad@heartcenteredcounselors.com MA LPCC LPCC.0015943 Jones Lilla 970-460-4136 lillaj@heartcenteredcounselors.com MA LPCC LPCC.0015850 Kintzley Mari 303-249-4024 marik@heartcenteredcounselors.com Bachelors Counseling Intern NA Long Matthew 970-430-6751 matthewl@heartcenteredcounselors.com MSW LSW LSW.0009922041 Nard Laurel 970-425-3987 laureln@heartcenteredcounselors.com MA LPCC LPCC.0015874 Nicholson JaneII 650-224-2718 janelln@heartcenteredcounselors.com MA LPCC LPCC.0016109 Norris Chelsea 970-775-8455 chelsean@heartcenteredcounselors.com MA LPCC LPCC.0015786 Roberson Taylor 843-503-1630 taylorr@heartcenteredcounselors.com MA LPCC LPCC.0016031 Rodriguez Meghan 970-424-4068 meghanr@heartcenteredcounselors.com MS LPCC LPCC.0015229 Shiveley Jessica 970-541-1015 jessicas@heartcenteredcounselors.com MSW LSW LSW.0009921972 Suljovic Daira 970-795-2903 dairas@heartcenteredcounselors.com Bachelors Counseling Intern NA Asbury Hope 970-400-1228 hopea@heartcenteredcounselors.com Bachelors Social Work Intern NA Bid No.: B1900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposenCIO 1TE® One Staff Data Sheet per proposed service. Bidder should not combine services.) Bid No.: 01900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposePDClmdlit® One Staff Data Sheet per proposed service. Bidder should not combine services.) Bid No.: B1900025 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeMeltiliE® One Staff Data Sheet per proposed service. Bidder should not combine services.) Bid No.: B1900025 HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP 111 -IPSO caa Certificate of In51nanre CLAIMS MADE POLICY FORM Print Date: 12/14/2018 Your professional liability insurance is written on a claims made basis and provides coverage for those claims which are the result of medical incidents occurring subsequent to the prior acts date stated and which are first made against you while this insurance is in force. Please discuss with your program Administrator. Producer Branch Prefix 018098 970 HPG Named Insured and Address: Heart -Centered Counseling, Inc. 320 W Olive St Fort Collins, CO 80521-2716 Policy Number 0622028318 Medical Specialty: Licensed Professional Counselor Firm Excludes Cosmetic Procedures Prior Acts Date: 01/01/16 Policy Period from 01/01/19 to 01/01/20 at 12:01 AM Standard Time Program Administered by: Healthcare Providers Service Organization 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034 1-888-288-3534 www.hpso.com Code: Insurance is provided by: 80723 American Casualty Company of Reading, Pennsylvania 333 S. Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $ 3,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability * Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection Defendant Expense Benefit Deposition Representation Assault Includes Workplace Violence Counseling Medical Payments First Aid Damage to Property of Others Information Privacy (HIPAA) Fines and Penalties General Liability General Liability Fire & Water Legal Liability Total: $52,062.00 $ 25,000 per proceeding $ 25,000 aggregate $ 1,000 per day limit $ 25,000 aggregate $ 10,000 per deposition S 10,000 aggregate $ 25,000 per incident $ 25,000 aggregate $ 25,000 per person S 100,000 aggregate $ 10,000 per incident $ 10,000 aggregate $ 10,000 per incident S 10,000 aggregate $ 25,000 per incident S 25,000 aggregate $1,000,000 each claim / $3,000,000 aggregate Included in the GL limit shown above subject to $250,000 aggregate sublimit Base Premium $52,062.00 Policy Forms & Endorsements(Please endorsements.) G -121500-D G -123815-A05 GSL15565 GSL17101 CNA81758 CNA82011 G -141235-A Chairman of the Board G -141230-A (03/2010) G-1215 GSL134 CNA795 see attached list for a general description of many common policy forms and 02-C 24 75 G -145184-A GSL13425 G -121504-C Secretary Coverage Change Date: G -147292-A CNA80052 G -123827-B GSL15563 G -123846-005 G -123828-B GSL15564 CNA81753 G -141231-A Keep this document in a safe place.lt and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in fuU.ln order to activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance. Master Policy # 188711433 Endorsement Change Date: POLICY FORMS & ENDORSEMENTS The following are the policy forms and endorsements that apply to your current professional liability insurance policy. COMMON POLICY FORMS & ENDORSEMENTS FORM # DESCRIPTION G -121500-D Common Policy Conditions G -123815-A05 State Endorsement G -121502-C Claims Made Policy Form G -145184-A Policyholder Notice - OFAC Compliance Notice G -147292-A Policyholder Notice - Silica, Mold & Asbestos Disclosure GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 Services to Animals GSL13425 Business Owner Coverage Extension Endorsement CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement G -123846-005 Colorado Cancellation and Non -Renewal CNA81753 Coverage & Cap on Losses from Certified Acts Terrorism CNA81758 Notice - Offer of Terrorism Coverage & Disclosure of Premium CNA82011 Related Claims Endorsement CNA79575 Exclusion of Cosmetic Procedures G -121504-C General Liability Form G -123827-B (02) Additional Insured General Liability G -123828-B Certificate Holder G -141231-A Additional Insured Healthcare Entity G -141235-A Additional General Liability Locations PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality and/or county level. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association - 2012 Regular Assessment. Form#: G -141230-A (03/2010) Named Insured: Heart -Centered Counse Master Policy#: 188711433 Policy#: 0622028318 Heart Centered Counseling 32o West Olive St. Fort Collins, CO 80521-2716 11/29/2°18 To: Beacon Health Options Re: Group Malpractice This letter is to confirm that the following providers are covered under our Group Malpractice Insurance with Policy number 0622028318 for the policy period °1/01/2018 through 01/01/2019. Thank you. Sincerely, Carla Eliza Amarillo Heart Centered Counseling Insurance) Claims( Benefits (Payroll( Beacon and Humana Email: carlaOpheartcenteredcounselors.com Text Message: 970-329-5195 Phone: 970- 372-6625 Fax: 97o-516-0655 Jodi Alieksaites, MA,LPC Stephanie Bagwell, Psy.D. Elissa Baker, MA, LPC Daniela Barou Thomas Barr Dena Beals Veronica Bechara, LCSW Jonathan Benz, M.A., LPCC Douglas Blocksma, MA, NCC, LPC Susan Bolint, MS, M.Ed., LMFT, LAC Ann Bomberg Tammy Boyer Jennifer Burnett, MSW, LCSW John Burton Alison Butler, MA, LPC, NCC Lesley Caldwell, LPC Laurel Carter, MA, LPC Jamie Castillo, M.A., LPC Sharon Cleveland Cynthia Chavez, LPC,MA,CACII Cynthia Collinsworth Abbie Conner, MSW, LCSW Krista Cowan Nadara Dauk Alyssa Davis Alyssa De La Torre Carole Diamond Amanda Dimmen-Klenk, M.S., LMFT Deborah Edsall Janis Edwards Blake Engelman, M.A., LPC Genesa Falcao, LPC Velvet Flint, LPC Denise Flores, LMFT Suzanne Foley, LPC Haley Ford, Ph.D. Ariel Friese, MC, LPC Monica Garcia, Psy.D. Deborah Gentry, MSW, LCSW Amanda Hand, MA, MNM, LPC Ginger Kipp Amy Healy Krumwiede Jami Hedrick Pedar Herom, MA, LPC Michael Herr Pamela Herrick Laurie Hessel, MSW, LCSW Diane Holliday, Masters Candidate Johanna Huemmler Linne Humbargar, MMS, PA -C Sharon Inglis Sonia Izmirian Kristin Jansen Katelyn Johnson Cheyenne Jones Mari Kintzley Sharlene Kraemer Jennifer Le Pont -Fowler, DNP Alexandra Leaderman, MA, LPC Dori Lewis, MA,Ed M, LPC Lauri Lohse, ARNP Matthew Long James Lutz Emily Mcdonald Gregory Mavrides, PhD Rena Mcdonell Terry Mcguire Tracy Meisinger Cheryl Mlcoch, M.S., LPC Kathryn Monnig, MA, LPC Kelsey Morrow Wright Angelica Morse, LCSW Stacy M usial Laurel Nard Lance Nabers Hali Neves, MA, LPC JaneII Nicholson Chelsea Norris Adrian Oxton, MA, LPC, LAC Natala Paraz, MSW, LCSW Mary Pike Anne Poler, MA, LCSW Cezar Popescu Mary Preston, LMFT Nathan Preston, LMFT Kathryn Price, MSW, LCSW Andrea Pucciarello, MSW, LCSW Laura Reid, LCSW Charity Rauls Mira Reisen Jay Ryser Kendall Kershner Rice Christopher Roney Taylor Roberson Meghan Rodriguez Adrienne Rogers Valeria Rojo Dalton Ross Amy Ryk Holly Schubert Brittani Schwintosky, APN Mark Scofield David Sehr Brody Shelstad Kimberly Shirk Jessica Shiveley, LSW Max Stager, MA, LPC, NCC Lauren Stanley, MSW, LCSW Melissa Stillman, M.S.Ed., LPC Tracy Stuart, LPC Daira Suljovic Linda Talarico, MSW, LCSW Marcella Thompson, LCSW Molly Torvik, MSN, FNP-C Abigail "Abbey" Towe Stephen A. Valente, MSW, LCSW Christina VanderBeek, MA,LPC Jay VanDerWerff, MSW, LCSW, LAC Kathleen Voelsing Jeffrey Vovilla Caitlin Walk Milena Walkowiak Kathryn Watt Michael Weitzel Cindy Wells Douglas Wenger Angela White James Kenneth Whitney Rebecca Wilson, MSW, Thomas Wilson Allison Woods, LPC (Policy Provisions: WC000000C) INFORMATION PAGE WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY INSURER: Trumbull Insurance Company ONE HARTFORD PLAZA HARTFORD CT 06155 NCCI Company Number: Company Code: H r 19666 POLICY NUMBER: Previous Policy Number: 76 WEG 1O8418 76 WEG 1O8418 1. Named Insured and Mailing Address: HEART CENTERED COUNSELING INC (No., Street, Town, State, Zip Code) 320 W OLIVE ST FORT COLLINS CO 80521 FEIN Number: 45-2668894 State Identification Number(s): The Named Insured is: Corporation Business of Named Insured: Offices of All Other Miscellaneous Health Practitioners Other workplaces not shown above: 2. Policy Period: From 01/11/19 To 01/11/20 ANNUAL 12:01 a.m., Standard time at the insured's mailing address. Producer's Name: AUTOMATIC DATA PROCESSING INS AGCY 1 ADP BLVD M/S 625 ROSELAND NJ 07068 Producer's Code: 76250873 Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER 3600 WISEMAN BLVD SAN ANTONIO TX 78251 (877) 287-1316 THE HARTFORD Suffix LARS RENEWAL 3 Total Estimated Annual Premium: $7,762 Deposit Premium: Policy Minimum Premium: $326 CO (Includes Increased Limit Min. Prem.) Audit Period: ANNUAL Installment Term: Four Pay (30%Down+2@25%+1 @20%) The policy is not binding unless countersigned by our authorized representative. Countersigned by cifCwt � 12/02/18 Authorized Representative Date Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page) Process Date: 12/02/18 Policy Expiration Date: 01/11/20 INFORMATION PAGE (Continued) Policy Number: 76 WEG 1O8418 3.A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states listed here: CO B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident $1,000,000 each accident Bodily injury by Disease $1,000,000 policy limit Bodily injury by Disease $1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here: ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE. D. This policy includes these endorsements and schedule: SEE ENDORSEMENT -WC 99 03 68 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Number and Description Premium Basis Total Estimated Rates Per Estimated Annual $100 of Annual Remuneration Remuneration Premium Total Standard Premium Premium Discount Expense Constant Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement Catastrophe (Other Than Certified Acts Of Terrorism) Estimated Annual Premium (before Surcharges) 'See the attached Schedule(s) of Operations for Location and State Level Premium Information $7,353 -$81 $160 $110 $220 $7,762 Total Estimated Annual Premium: Deposit Premium: Policy Minimum Premium: $7,762 $326 CO (Includes Increased Limit Min. Prem.) Interstate/Intrastate Identification Number: Refer to Schedule of Operations NAICS: 621399 Labor Contractors Policy Number: SIC: Form WC 00 00 01 A (1) Printed in U.S.A. Page 2 Process Date: 12/02/18 Policy Expiration Date: 01/11/20 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Medication Management Services and Mental Health Services, as referred by the Department. 2. Under this agreement, Contractor will offer the following services: a. Mental Health Services i. Individual Therapy ii. Couples Family Therapy iv. Group Therapy v. Assessments 1. Diagnostic psychological assessment 2. Learning Disability assessments 3. Substance use disorder assessment vi. Neuro-psychological Testing/Evaluations 1. Administration of psychological evaluations/testing 2. Interpretation of psychological evaluations/testing b. Medication Management Services i. Initial medication evaluations ii. Ongoing medication management services 3. Capacity for Services: Monday through Friday, 7:30 a.m. to 8:00 p.m. Contractor does not offer some weekend availability on Saturdays. 4. Goals of Service: a. Help individuals recover from mental health and substance use disorder issues. b. Offer clients therapy that meets their needs to help them recover and heal from trauma. c. Immediate availability with 90% of clients scheduled within one (1) week. 5. Outcomes of Service: a. Provide excellent mental health and substance use disorder treatment. b. Clients offered an initial appointment with seven (7) days. c. Offer up to four (4) appointments within 45 days of the first appointment, resulting in weekly sessions for clients. d. Ongoing clinical supervision and consultation for all our therapists. 6. Target Population: a. Young children b. Adolescents c. Adults (young, middle-aged and elderly, as well as couples) d. Families 7. Service Access: a. Greeley i. 1770 25th Avenue, Suite 206 ii. 1770 25th Avenue, Suite 202 iii. 1013 37th Avenue Court, Suite 101 1 b. Loveland i. 1032 North Lincoln Avenue ii. 1413 West 29th Street iii. 323 East 27th Street c. Fort Collins i. 320 West Olive Street ii. 1525 Riverside Avenue iii. 1531 Riverside Avenue iv. 1537 Riverside Avenue d. Littleton i. 5911 South Middlefield Road, Suite 100 ii. 5911 South Middlefield Road, Suite 200 e. Denver i. 950 East Harvard Avenue, Suite 670 f. Castle Rock i. 410 South Wilcox Street g. Tele-therapy and medication management available through secure video conferencing. 8. Language: English and Spanish. 9. Contractor will respond to the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 10. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). 11. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. After three (3) "no-shows, "Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team Supervisor (hainleidPweldgov.com, 970-400-6210). 12. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com) immediately via email, to discuss service continuation. 13. 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. 2 14. 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. 15. 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. 16. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 17. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. Contractor may participate by phone, if approved by the Department. 18. Contractor will notify the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400-6210) of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 3 EXHIBIT D RATE SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 2020. 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 Medication Management: $65.00/15 min (Medication Management) $150.00/Episode (Medication Management Evaluation) $95.00/30 min (Medication Management, discount) Mental Health Services: $95.00/Hour (Assessment) $120.00/Hour (Neuropsychological Evaluation) $85.00/Hour (Outpatient Psychotherapy, Master's Level) $93.00/Hour (Outpatient Psychotherapy, Ph.D. Level) 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. 1 Hello