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Home My WebLink About20192018.tiffn -Fr of C -F =O it ti CoCo (o PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: April 20, 2021 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment with Collaborative Services for Change PC 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 Collaborative Services for Change PC. The Department entered into a Child Protection Agreement for services with Collaborative Services for Change PC, identified as Tyler ID 2019-2018 on May 29, 2019. The Agreement was amended on August 28, 2019 to amend the Contractor's Request for Proposal, Scope of Services, and Rate Schedule. The Agreement was amended again on May 11, 2020 to extend the term date through May 31, 2021. The Agreement is now being amended to renew for a third and final year, for the period of June 1, 2021 through May 31, 2022 and to make changes to the Rate Schedule as noted below. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Mental Health Services x+085.00/flour (Oise Management) S-1-2431 50.00/Episodle (EMDR -- 90 -minute Session) $-1.00130.00/Hour (Family Session, 50 -minute Session) $440130.00/Hour (Individual Session, 50 -minute Session) $84100.00/Hour (Team Meetings or Staffing, 50 -minute Session) Sexual Abuse Treatment $85.00/I lour (Case Management) $J28150.00/Episode (EMDR -- 90 -minute Session) $4401 30.00/Hour (Family Session, 50 -minute Session) $-1-09130.00/Hour (Individual Therapy, 50 -minute Session) $84100.00/Hour (MDT, Team Meetings or Staffing, 50 -minute Session) Pass -Around Memorandum; April 20, 2021— ID 4666 Page 1 Ofinien-i- otiracorai cd-,.GLie),"_ea-ksP) 0019-aols- �-►Roogp PRIVILEGED AND CONFIDENTIAL I do not recommend a Work Session. I recommend approval of this Agreement Amendment. Perry L. Buck Mike Freeman Scott K. James, Pro-Tem Steve Moreno, Chair Lori Saine /04"1 - Approve Schedule mendation Work Session Other/Comments: Pass -Around Memorandum; April 20, 2021— ID 4666 Page 2 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND COLLABORATIVE SERVICES FOR CHANGE PC This Agreement Amendment, made and entered into O7-Ck da of 2021 by and between the Board of Weld County Commissioners, on behalf of the Weld County epartment of Human Services, hereinafter referred to Es the "Department", and Collaborative Services for Change PC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services and Sexual Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2018, approved on May 29, 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: August 28, 2019 to amend the Contractor's Request for Proposal, Scope of Services, and Rate Schedule. May 11, 2020 to extend the term date through May 31, 2021. The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2019-2018. • 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. 2. Exhibit D, Rate Schedule, is hereby amended as attached. • All other turns 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: dit/LA)'" `'dO;t1 Weld C • n Clerk t By: //; Deputy Clerk the Bo rd BOARD OF COUNTY COMMISSIONERS WELI OUNTY, COLORADO Steve Moreno, Chair APR 2 6 2021 CONTRACTOR: Collaborative Services for Change PC 2480 West 26' Avenue, Suite 130-B Denver, Colorado 80211 By: Date: Mafzi fftewe; Lark Marti,ewr,., w,b,1..:,11U.14o.; Marci Brewer, Co -Owner and Clinical Director Apr 12, 2021 020 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, 2022. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures aid shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Mental Health Services Rate Unit Type Service Name $150.00 Episode EMDR — 90 -minute Session $130.00 Hour Family Session, 50 -minute Session $100.00 Hour Healthy Sexuality/Boundaries Curriculum — 50 -minute Session $130.00 Hour Individual Session, 50 -minute Session $100.00 Hour Team Meetings or Staffing, 50 -minute Session Sexual Abuse Treatment Rate Unit Type Service Name $150.00 Episode EMDR — 90 -minute Session $130.00 Hour Family Session, 50 -minute Session $100.00 Hour Healthy Sexuality/Boundaries Curriculum — 50 -minute Session $130.00 Hour Individual Therapy, 50 -minute Session $100.00 Hour Informed Supervision Training, 50 -minute Session $100.00 Hour MDT, Team Meetings or Staffing, 50 -minute Session Mentoring Rate Unit Type Service Name $65.00 Hour Mentoring, direct client contact — Face -to -Face, telephone or digital means communication $100.00 Hour Mentoring with Animal -assisted Therapy (AAT), direct client contact — Face-to-face, telephone or digital means communication 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 produc . For Monitored Sobriety services, proof of services rendered shall be the test result. New Contract Request Entity Information Entity Name* COLLABORATIVE SERVICES FOR CHANGE PC Entity ID* @00037136 Contract Name* Contract ID COLLABORATIVE SERVICES FOR CHANGE PC (AGREEMENT 4666 AMENDMENT) Contract Status CTB REVIEW Contract Description* BID 4-81900025 TERM: 6,' 1 ; 21-5;`31 '22. Contract Lead* AP'EGG ❑ New Entity? Parent Contract ID 20192018 Requires Board Approval YES Contract Lead Email Department Project* ape ggg•we ld gov. com. cobbx x I k ,veldgvv.com Contract Description 2 CONSENT. PA IS BEING ROUTED THROUGH THE NORMAL PROCESS. ETA TO C:T6 22;'21. Contract Type* AMENDMENT Amount* S0.00 Renewable* NO Automatic Renewal Grant ICA Department HUMAN SERVICES Department Email CM - H u ma n S e rvi ce stfoNe ld gov. co m Department Head Email CM-Human.Seivices- DeptHeadOweldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email C.M - COU NTYATTORNEYZbWELDG OV.CON1 Requested BOCC Agenda Date' 05, 26;`2021 Due Date 05,222021 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewalenter 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* 0401'2022 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name. Purchasing Committers Delivery Date Contact Type Contact Email Expiration Date* 05 =`31 2022 Contact Phone 1 Contact Phone 2 Purchasing Approver Purchasing Approved Date CONSENT 04;14!2021 Approval Process Department Head JAMIE ULRICH DH Approved Date 04;14:2021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 04'26:'2021 Originator APEGG Finance Approver CONSENT Legal Counsel CONSENT Finance Approved Date Legal Counsel Approved Date 04 14r 2021 04 14;`2021 Tyler Ref # AG 042621 c_67,7f-rzst,d- _3V41;3511 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 Page I Cori-SPrk-i", 49,ceto`4t' ©s /0 120 /45V On ©57/A/?� 2®1.1-2®18 1.4-'800qo VENDOR RENEWALS Vendor Program Area Service Name Family Interactional Evaluation Funding Core Rate $ 375.00 Unit Type Hour Inservice Training for Caseworkers and Foster Parents CW Block $ 175.00 Hour Inservice Training for Caseworkers and Foster Parents CW Block $ 600.00 1/2 Day Mental Health Assessment Core $ 375.00 Hour Psychological Evaluation Core $ 375.00 Hour Staffing, Family Team Meetings, TDM, Court, etc. Core $ 175.00 Hour Brien, Jessica Home Studies Additional Face -to -Face Time CW Block/Child Welfare Services $ 50.00 Hour Additional Travel Fee CW Block/Child Welfare Services $ 150.00 Episode Extra Adult(s) After First Two (2) CW Block/Child Welfare Ser/ices 5 100.00 Each Home Study Update CW Block/Child Welfare Services $ 700.00 Episode Home Study, 2 Adults CW Block/Child Welfare Services $ 1,600.00 Episode Mileage CW Block/Child Welfare Services $ 0:56 Mile Partial Home Study, Denied or Withdrawn CW Block/Child Welfare Services $ 300.00 Episode Centennial Board of Cooperative Education Services Day Treatment Services Therapeutic Et Educational Costs Core $ 203.00 Day Therapeutic Costs Core $ 72.00 Day Collaborative Services for Change Child Mentoring and Family Support Mentoring Core $ 65-00 Hour Mentoring - In Home/Community Core $ 97.50 Hour Mentoring with Animal Assisted Therapy (AAT) Core $ 100.00 Hour Mentoring with Animal Assisted Therapy (AAT) - In Home/Community Core $ 150.00 Hour Transportation Core $ 0.56 Mental Health Services Case Management Core $ 85.00 Hour EMDR 90 -Minute Session Core $ 120.00 Episode Family Therapy Core $ 100.00 Hour Health Sexuality/Boundaries Curriculum Core $ 100.00 Hour Individual Therapy Core $ 100.00 Hour Team Meetings or Staffing Core $ 85:00 Hour Sexual Abuse Treatment Case Management Core $ 85.00 Hour EMDR Therapy Session Core $ 120.00 - Episode Family Therapy Core $ 100.00 Hour Health Sexuality/Boundaries Curriculum Core $ 100.00 Hour Individual Therapy Core $ 100.00 Hour Informed Supervision Training Core $ 100.00 Hour MDT, Team Meetings or Staffing Core $ 85.00 Hour Colorado Boys Ranch Home Based Services CBR-HB (Per -Diem) Core $ 54.00 Day CBR-HB, High Package Core $ 1,900.00 Month CBR HB, Low Package Core $ 900.00 Month CBR-HB, Moderate Package Core $ 1,450.00 Month Community Connections Core $ 55.00 Hour Small Group Options Core $ 48.00 Hour Specialized Mentoring Core $ 55.00 Hour Life Skills Supervised Visitation Core $ 68.00 Hour Transportation for Visitation Core $ 40.00 Hour Crossroads Counseling Sexual Abuse Treatment Sexual Abuse Treatment -Hourly Rate Core $ 80.00 Hour David Kalis, Inc. dba Parker Personal Care Homes Domestic Violence Intervention Anger Management Treatment - in Office CW Block/Child Welfare Services $ 125.00 Hour WELD COUNTY DEPT. OF HUMAN SERVICES - CHILD WELFARE DIVISION 2020-21 SERVICE VENDORS (CORE/NON-CORE( BID NO.: 62000037 Ca 11--er.j- 33q/ written. AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND COLLABORATIVE SERVICES FOR CHANGE, PC 191 This Agreement Amendment, made and entered into �� day of / 2020 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Sery es, hereinafter referred to as the "Department", and Collaborative Services for Change, PC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Treatment and Sexual Abuse Treatment the ("Original Agreement') identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2018, approved on May 29, 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. • The Original Agreement was amended on August 28, 2019. The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2019-2018. • 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. • 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 COUNTY: ATTEST: V• JdD:ti Weld County Clerk to the Board By: eputy Clerk to the Board BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO Mike Freeman, Chair MAY 1 12020 CONTRACTOR; Collaborative Services for Change, PC 2480 West 26th Avenue, Suite 130-B Denver, CO 80211 By: Date: Nani Si-ewm LCDfiv Marci Brewer, LCSW (Apr 27, 2020) Marci Brewer, Co -Owner and Clinical Director Apr 27, 2020 Gaet,4 ©5/1/43 cc H8o onba$e osi la l as etc'-2oig H-Rocgo Contract Farm Entity Information New Contract Request Entity Name* Entity ID* COLLABORATIVE SERVICES FOR @00037136 CHANGE PC ❑ New Entity? Contract Name* Contract ID COLLABORATIVE SERVICES FOR CHANGE PC (AGREEMENT 3591 AMENDMENT) Contract Status CTB REVIEW Contract Lead* CULLINTA Contract Lead Email cullinta@comeld co us Parent Contract ID Requires Board Approval YES Department Project # Contract Description* CONSENT. BID NO. 2000037. BOCC APPROVAL 04/15/20 CHILD PROTECTION AGREEMENT AMENDMENT TERMS: 06/01/20 THROUGH 05/31/21 FUNDING: CORE/OTHER. Contract Description 2 Contract Type* AGREEMENT Amount* $0.00 Renewable* NO Automatic Renewal Grant ICA 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- COUNTYATTORNEY@WELD GOV.COM Requested BOCC Agenda Date* 04/15/2020 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 MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in Onaase Contract Dates Effective Date Review Date* Renewal Date 04/0112021 Termination Notice Period Committed Delivery Date Expiration Date* 05/31/2021 Contact Information Contact Info Contact Nance Purchasing Purchasing Approver Approval Process Department Head JAMIE ULRICH DH Approved Date 05/05/2020 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 05/11/2020 Originator SNYDERKL Contact Type Contact Email Finance Approver BARB CONNOLLY Contact Phone 1 Contact Phone 2 Purchasing Approved Date Finance Approved Date 05/06/2020 Tyler Ref # AG 051120 Legal Counsel GABE KALOUSEK Legal Counsel Approved Date 05/06/2020 Submit r�-f rr�ct tJ ��I 18' PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: July 23, 2019 TO: Board of County Commissioners — Pass -Around FR: Judy A. Griego, Director, Human Services RE: Department of Human Services' Agreement Amendment with Collaborative Services for Change, PC 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 Collaborative Services for Change, PC. The Department entered into an agreement with Collaborative Services for Change, PC, with a term of June 1, 2019 through May 31, 2020, for Mental Health Services and Sexual Abuse Treatment. This agreement is identified as 2019-2018, approved on May 29, 2019. At this time the Department would like to add Mentoring as an available service under the agreement. The specific provisions of this addition include: • $65.00/Hour (Mentoring, direct client contact — Face -to -Face, telephone or digital means communication) • $100.00/Hour (Mentoring with Animal -assisted Therapy (AAT), direct client contact — Face-to-face, telephone or digital means communication) • Mileage Catchment — Hourly rate plus half within the first 30 miles. $.56/Mile (Each additional mile beyond 30 miles. I do not recommend a Work Session. I recommend approval of this amendment. Sean P. Conway Mike Freeman, Pro-Tem Scott James Barbara Kirkmeyer, Chair Steve Moreno Approve Schedule Recommendation Work Session Other/Comments: Pass -Around Memorandum; July 23, 2019 — CMS 2918 Page 1 0_,ov\serv-t- cizt. Ogt 8$t l ct 0019-aolg E-lRoo to AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND COLLABORATIVE SERVICES FOR CHANGE, PC This Agreement Amendment, made and entered into 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 Collaborative Services. for Change,. PC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services and Sexual Abuse Treatment, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-2018, approved on May 29, 2019. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement, 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 Mav 31, 2020. • The Amendment, together with the Original Agreement, constitutes the entire understanding between the parties. The following change is hereby made to the Contract Documents: 1. Exhibit B, Contractor's Response to Request for Proposal, amended as attached. 2. Exhibit C, Scope of Services, amended as attached. 3. Exhibit D, Rate Schedule, amended as attached • All other terms and conditions of the Original Agreement remain unchanged. 1 O01`t- Q01g IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: Wel B .scito;‘,k. BOARD OF COUNTY COMMISSIONERS Clerk to the : oard _ WELD COUNTY, COLORADO Deputy C irk to the B 2 Mike Freeman, Pro-Tem CONTRACTOR: AUG 2 & 2019 Collaborative Services for Change, PC 2480 West 26th Avenue, Suite 130-B Denver, CO 80211 By: Hata'37-ewm Lark Marci Brewer, LCSW IJun?7,?0191 Marci Brewer, Co -Owner and Clinical Director Jun 27, 2019 Date: 0019 -a0 �� EXHIBIT B CONTRACTOR'S RESPONSE TO REQUEST FOR PROPOSAL ocOtiVe S O`Co � u O O 2480 West 26th Avenue, Suite 130-B • Denver, CO 80211 • Phone: 303-433-0188 • Fax: 303-433-6145 1-21-19 To Whom It May Concern: This letter is to serve as a formal bid to Weld County Department of Human Services for Marci Brewer, LCSW to continue providing services for the upcoming 2019-20 fiscal year. Collaborative Services for Change, PC is a private S -Corporation with two owners, Marci Brewer, LCSW and Jeff Kisicki, LCSW. This contract for services is specifically for Marci Brewer, LCSW as a service provider. Collaborative Services for Change is committed to providing services to individuals, couples, families and youth, working to improve the quality of their relationships and ability to realize their full potential in daily functioning. Through a collaborative, culturally sensitive and holistic approach, we design personalized treatment plans, offering particular expertise in the areas of promoting healthy relationships, recovery from trauma and/or victimization, sexual abuse treatment, issues related to stress management, depression and anxiety, and supporting the development of life skills and behavior management for those with special needs. Our practice is centrally located in Denver, Colorado, in close proximity to 125, Rt. 6, and along the RTD Bus Routes. Current contact information is noted on the above letterhead, serving as both our physical address and our mailing address. Collaborative Services is not a Medicaid Provider. As the attached resume will detail, this clinician offers over 26 years' experience as a Licensed Clinical Social Worker with evidenced capacity to deliver quality services as identified in Exhibit A. Said services have been evidenced for WCDHS, having been a long standing provider, as well as services being conducted in a myriad of environments throughout this clinician's professional experience. In addition, this clinician is CO SOMB (Sex Offender Management Board) approved (since its inception 2002) as a Full Operating Treatment Provider, including a specialty in treating those with Developmental Delays. Proof of this inclusion with the SOMB can be found on their website, on the provider listings. Moreover, this clinician is trained in EMDR (Eye Movement Desensitization and Reprocessing) Therapy, Levels 1 and II. Thus, both specific training and many years of successful clinical experience are evidenced as expertise in the field. Referrals may be presented to Marci Brewer, LCSW via email or phone. Responses to confirm recognition and/or acceptance of said referral will be sent within 48 business hours. Past contracting and working agreements may serve as further evidence of this clinician's responsiveness to referrals and related quality of services provided. Please see the attached materials. Thank you for this opportunity to continue our work with WCDHS. Respectfully submitted, Marci Brewer, LCSW EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Collaborative Services for Change. PC 19166 AGENCY OR PRIVATE PRACTICE TRAILS PROVIDER ID (If Known) Marci Brewer, LCSW PRIMARY CONTACT — FULL NAME 1 303 ) PHONE NUMBER 433-0188 mbrewer aacollaborativeservices4change.com PRIMARY CONTACT— E-MAIL ADDRESS 2480 W. 26th Ave Suite 130-8 AGENCY MAILING ADDRESS Clinical Director PRIMARY CONTACT - TITLE ( 303 )433-6145 EXT. FAX NUMBER AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) Denver 80211 CITY ZIP Marci Brewer, LCSW REFFERAL CONTACT— FULL NAME SAME ( 1 SAME REFERRAL CONTACT— PHONE NUMBER REFERRAL CONTACT EXT. SAME REFERRAL CONTACT - TITLE SAME REFERRAL CONTACT — E-MAIL ADDRESS BILLING CONTACT Marci Brewer. LCSW BILLING CONTACT — FULL NAME ( ) SAME BILLING CONTACT— PHONE NUMBER EXT. SAME BI W NG CONTACT - TITLE SAME BILUNG 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. 1 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: Marci Brewer, LCSW Date of Signature: 1-21-19 Bid No.: B1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: 2. Program name or service type being proposed: Collaborative Services for Change, PC Mental Health Treatment 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. MODALITIES: Individual Therapy Family Therapy EMDR (Eye Movement Desensitization and Reprocessing) Therapy Healthy Sexuality/Boundaries Curriculum Staffings Case management Court Testimony as needed CURRICULUM, TOOLS, CLINICAL FRAMEWORK: Cognitive Behavioral Therapy Family Systems Therapy Trauma Recovery EMDR (Eye Movement Desensitization and Reprocessing) Therapy 4. Capacity to Provide Services (ex. 4 hours/week). Varies, from 1-10 hours/week 5. Goals of the service. Per the WCDHS definition of service, this clinician concurs: Mental Health service should improve the clients' mental health, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. Interventions should address child welfare specific needs such as the consequences of loss and grief, and abuse and neglect, and assist in building resiliency. 6. Outcomes of service. Within the context of a therapeutic relationship the client should experience psychological safety while gaining improved self-observation skills, cognitive insight, cognitive restructuring skills, emotional recognition, increased emotional self -regulation, awareness of behavioral functioning (both past and present), recognition of harm done (if applicable), improved coping strategies for overall behavioral regulation, improved relationships, in addition to decreased risk and increased health and resiliency toward overall improved functioning. 7. Target population for service. Individual Youth 10-21YOA; Families/Couples; Team Members. Specialty services designed for the Developmentally Disabled are available as needed. 8. Service access. In office services: 2480 W. 26th Ave, Suite130-B Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE Denver, CO 80211 303-433-0188 Phone conferencing available; no capacity for video conferencing Community based services, such as Staffings, may be conducted in the home, school, WCDHS or courthouse as is necessary and upon this clinician's availability. Travel time will be included in the service billed. 9. Languages service is available in. English only 10. Rates of service. ***revised 2-25-19 Rates: a. Individual Therapy b. Family Therapy c. EMDR Therapy Session d. Staffing/MDT/FTM e. Case Management Services 15min increments as needed) f. Healthy Sexuality/Boundaries Curriculum $100.00 per 50 min hour g. Court Testimony $100.00 per 50 min hour h. Travel time, if applicable, will be added to the service delivered at that rate Bid No.: 1900025 $100.00 per 50 min hour $100.00 per 50 min hour $120.00 per 90 minute session $85.00 per 50 min hour $85.00 per 60 min hour (to be billed in EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: 2. Program name or service type being proposed: Collaborative Services for Change, PC Sexual Abuse Treatment 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. MODALITIES: Individual Therapy Family Therapy EMDR (Eye Movement Desensitization and Reprocessing) Therapy Healthy Sexuality/Boundaries Curriculum Informed Supervision Trainings Staffings Case management Court Testimony as needed CURRICULUM, TOOLS, CLINICAL FRAMEWORK: Cognitive Behavioral Therapy Family Systems Therapy Trauma Recovery EMDR (Eye Movement Desensitization and Reprocessing) Therapy Colorado Sex Offender Management Board Juvenile Standards 4. Capacity to Provide Services (ex. 4 hours/week). Varies, from 1-10 hours/week 5. Goals of the service. Per the WCDHS definition of service, this clinician concurs: Therapeutic intervention designed to address issues and behaviors related to sexual abuse victimization, sexual dysfunction, sexual abuse perpetration, and to prevent further sexual abuse and victimization. It is expected that for criminal sex abuse cases, the provider will attend Multi -Disciplinary Team Meetings to provide input, insight and guidance into progress, safety planning, and next steps. Psycho -education for parents re: victim and perpetrator issues such as clarification and reunification, family therapy, informed supervision, safety planning, and general boundaries. 6. Outcomes of service. Within the context of a therapeutic relationship the client should experience psychological safety while gaining improved self-observation skills, cognitive insight, cognitive restructuring skills, emotional recognition, increased emotional self -regulation, awareness of behavioral functioning (both past and present), recognition of harm done (if applicable), improved coping strategies for overall behavioral regulation, improved relationships, in addition to decreased risk and increased health and resiliency toward overall improved functioning. 7. Target population for service. Individual Youth 10-21YOA; Families/Couples; Containment or MDT Members/Informed Supervisors. Specialty services designed for the Developmentally Disabled are available as needed. Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE 8. Service access. In office services: 2480 W. 26th Ave, Suite130-B Denver, CO 80211 303-433-0188 Phone conferencing available; no capacity for video conferencing Community based services, such as MDT Staffings, may be conducted in the home, school, WCDHS or courthouse as is necessary and upon this clinician's availability. Travel time will be included in the service billed. 9. Languages service is available in. English only 10. Rates of service. ***revised 2-25-19 Rates: a. Individual Therapy b. Family Therapy c. EMDR Therapy Session d. Staffing/MDT/FTM e. Case Management Services min increments as needed f. Informed Supervision Training $100.00 per 50 min hour g. Healthy Sexuality/Boundaries Curriculum $100.00 per 50 min hour h. Court Testimony $100.00 per 50 min hour i. Travel time, if applicable, will be added to the service delivered at that rate $100.00 per 50 min hour $100.00 per 50 min hour $120.00 per 90 minute session $85.00 per 50 min hour $85.00 per 60 min hour {to be billed in 15 Bid No.: 1900025 STAFF DATA SHEET EXHIBIT D (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not combine services.) PROPOSED SERVICE OR SERVICE TYPE: Mental Health Treatment Collaborative Services for Change APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION SUPERVISOR INFORMATION No. Last Name First Name Work# Work Email Education Level - Degree Focus Ucensure/ Credentials :• DORA # (If applicable), Last Name First Name Work#• Work Email 1 Brewer Marci 303-433-0188 mbrewer@collaborativeservices4chanse.com 2 3 Master's Social Work LCSW 991181 N/A 4 5 6 7 8 9 10 11 12 . 13 14 - 15 16 17 18 19 20' 21 22 23 24 25 26 27 28 Bid No.: B1900025 STAFF DATA SHEET EXHIBIT D Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not combine services.) PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: Sexual Abuse Treatment Collaborative Services for Change - APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION SUPERVISOR INFORMATION No. Last Name - First Name Work# Work Email Education Level ' Degree Focus Licensure/ Credentials DORA # (If applicable) Last Name First Name Work # Work Email 1 Brewer Marci 303-433-0188 mbrewerPcollaborativeservices4chanRe.com 2 3 Master's Social Work LCSW 991181 , 4 5, 6 7 8. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Bid No.: 81900025 MARCI M. BREWER, LCSW EDUCATION Post -Graduate Clinical Training, September 1993 - September 1995 Colorado Institute for Marriage and the Family, Boulder, Colorado Master of Social Work, June 1991 University of Denver, Denver, Colorado Bachelor of Science in Social Work, May 1987 Bowling Green State University, Bowling Green, Ohio CREDENTIALS Licensed Clinical Social Worker Colorado License Number 991181, October 1993 Approved Juvenile Full -Operating Treatment Provider, with Developmental Disability Specialty, and Full -Operating Evaluator, via the Colorado Sex Offender Management Board, 2002 to present EMDR (Eye Movement Desensitization and Reprocessing) Trained: Level I and II, May 2012 EXPERIENCE Collaborative Services for Change, PC, Denver, Colorado Clinical Director and Co-owner, June 2004 to present • Provide outpatient mental health therapy for individuals, couples, youth and families focusing on a variety of presenting issues, utilizing a strength based, systemic and cognitive behavioral approach including: o Recovery from sexual victimization o Trauma recovery o Family issues and Parenting o Relationship improvement o Anger management o Behavior disorders o Mood disorders o Issues with stress, anxiety and/or affect regulation o Life stage transitions o Social skills intervention o Teen parenting education • Provide EMDR (Eye Movement Desensitization and Reprocessing ) Therapy • Develop and implement outpatient treatment programming that is sexual offense specific for juveniles, including the following services: o Offense specific evaluations o Intake assessments o Individualized treatment planning o Treatment for special needs youth, developmentally disabled youth and those with dual diagnoses who have evidenced sexually abusive acting out o Individual, group, and family therapy o Field therapy Marci M. Brewer, LCSW Page 2 o Polygraph preparation o Healthy sexuality and boundaries curriculum o Informed supervision trainings o Case management, staffings and court testimony as needed • Provide holistic mental health treatment programming for special needs, developmentally disabled youth, and those with dual diagnoses • Economic Offender Programming via Denver County Adult Probation 2004 -2018 o Program development o Implement group and individual therapy services • Provide on -site program consultation and foster parent training • Provide professional trainings The University of Denver Graduate School of Social Work Adjunct Professor, January 2012 • Taught graduate level course in: Cognitive Approaches to Social Work Practice Winter Quarter 2012 • Developed and designed curriculum for coursework • Facilitated an engaging learning environment and administered related assignments • Conducted student evaluation and grading The Resource Center for High Risk Youth, Denver, Colorado Clinical Supervisor, January 2003 — June 2004 Clinician, May 1999 - January 2003 • Completed sexual offense specific evaluations and risk assessments for juveniles • Completed thorough intake assessments for admission and developed personalized treatment plans • Provided outpatient, sexual offense specific family, individual and group therapy with both male and female clients of all ages, based upon the philosophy of Containment Theory • Facilitated containment staffings with related case management, report writing and court testimony as needed • Created and co -facilitated a Multi -family Group • Created and presented a bi-monthly psycho -education class on Informed Supervision and Therapeutic Care • Supervised clinicians and MSW Student Intern(s) • Assisted in administrative duties and agency program development Private Practice, August 1993 — June 2004 • Private practice on a part-time basis, conducting individual, family, marital and group therapy to a variety of outpatient clientele (2002 - 2004) • Conducted contract work with Therapeutic Alliance, including individual, family and group therapy (2001 - 2004) • Conducted a six week Foster Parent Training seminar for Denver Area Youth Services (1997) • Facilitated a parent support group under contract for the Denver Family Therapy Center (1993) Marci M. Brewer, LCSW Page 3 Shiloh House, Inc., Littleton, Colorado Clinician, February 1997 — May 1999 • Provided family, group and individual therapy, within a continuum of residential, day treatment, in -home and community -based settings • Effective intervention with high risk clientele, including such populations as sexual offense specific, juvenile delinquency and emotionally disturbed children and adolescents • Conducted sexual offense specific evaluations and court reports • Performed ongoing assessment, case coordination and multi -disciplinary treatment_ planning • Facilitated a Multi -family Group • Conducted crisis intervention and behavior management for the programs, and clinical training for the -staff Colorado Christian Home, Denver, Colorado Residential Unit Supervisor, April 1995 - December 1996 • Managed a residential treatment unit for severely traumatized children and their families • Facilitated individual and group supervision for a clinical staff of 18 • Provided family, group, and individual therapy with related case management • Created innovative residential programming based upon the concept of positive peer culture • Provided ongoing leadership through team process, training, and direct milieu management • Performed rotating emergency clinical supervision of entire residential agency • Responsible for overall operations including hiring, staff development, scheduling, evaluations, and financial budgeting Denver Children's Home, Denver, Colorado Family Therapist, After School and Day Treatment Programs, July 1991 - April 1995 • Assessed intensive outpatient clientele, and developed treatment plans accordingly • Provided family, marital, individual, and group therapy, with court reports and testimony • Coordinated all cases with multiple social agencies and schools • Conducted crisis intervention and behavior management • Supervised MSW Intern Bethesda PsycHealth System, Denver, Colorado Social Work Intern, August 1990 - June 1991 • Conducted family and marital therapy • Co -facilitated a parent support group and a women survivors of sexual abuse group • Presented school in -services Florence Crittenton Services, San Francisco, California Group Counselor, July 1989 - June 1990 • Provided individual counseling, group therapy, crisis intervention and parenting education for adolescent mothers and their children Marci M. Brewer, LCSW Page 4 Sunny Hills Children's Services, San AnseImo, California Residential Counselor, September 1988 - June 1990 • Conducted individual counseling and group therapy for severely disturbed adolescents Henry County Department of Human Services, Napoleon, Ohio Social Services Worker III, January 1987 - May 1988 • Provided counseling and case management services for protective and ongoing caseload • Investigated reports of child abuse, neglect and dependency, including court testimony • Organized and implemented a day care program • Conducted custody and friend of the court investigations • Co -facilitated a therapy group for both survivors and perpetrators of sexual abuse Henry County Court of Common Pleas, Napoleon, Ohio Guardian Ad Litem, December 1987 - May 1988 • Advocated for the best interests of alleged sexually abused children and provided court testimony accordingly CONFERENCES AND PROFESSIONAL TRAININGS CONDUCTED • Co -facilitated a sexual offense specific conference for the Department of Youth Corrections (Denver, CO 2000) •. Presented three, eight -hour conferences for the Colorado Sex Offender Management Board on: Informed Supervision and Therapeutic Care (2-18-03 Fort Collins, CO; 2-26-03 Colorado Springs, CO and 3-14-03 Grand Junction, CO) • Co -facilitated a 90 -minute conference for the Colorado Child and Adolescent Mental Health Coalition on: Sexually Abusive Youth: A Treatment Framework (3-14-04 Colorado Springs, CO) • Co -facilitated a one -day conference for the Colorado Sex Offender Management Board on: Individualized Treatment Planning and Intervention with Juvenile and Adult Sex Offenders (4-7- 05 Denver, CO) • Co -facilitated a half -day conference sponsored by the Colorado Sex Offender Management Board Victim Advocacy Committee on: Victim Representation on Sex Offender Supervision Teams (10-13-06 Denver, CO) • Provide ongoing Informed Supervision and Therapeutic Care Trainings for multi -disciplinary team members, to present • Presented a professional training for the Colorado Sex Offender Management Board on: Treatment Interventions for Juveniles Who Have Sexually Acted Out (4-28-11 Denver, CO) • Presented a professional training for the Department of Youth Corrections on: Building Victim Awareness: Being Victim Centered, Impacts to Victims, Clarification and Reunification Considerations (3-8-13) PUBLICATIONS • Chapter "Multi -Family Group Therapy for Sexually Abusive Youth" included in the Journal of Aggression, Maltreatment and Trauma, and in the book entitled Identifying and Treating Juvenile Sex Offenders: Current Approaches, Research, and Techniques, Haworth Press, 2004. Account Number: CO COLL 2480 Date: 8/31/18 Initials: LPD CERTIFICATE OF INSURANCE ALLIED WORLD INSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800-421-6694 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named Insureds) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Named Insured: COLLABORATIVE,SERVICES FOR CHANGE PC 2480 W 26TH AVE STE 130B DENVER CO 80211 Additional Named Insureds: JEFF KISICKI MARCI MANDEL BREWER MATT MOCK Type of Work Covered: SOCIAL WORKERS / PROFESSIONAL SOCIAL WORKER Location of Operations: N/A (If different than address listed above) Claim History: None Retroactive date is 09/03/2004 Coverages Policy Number Effective Date Expiration Date Limits of Liability PROFESSIONAL/ LIABILITY 5600-4945 9/03/18 9/03/19 2,000,000 4,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: Defense Reimbursement Proceedings Limit is $35,0O0. 3 ADDL.INS.BELOW: JEFFERSON COUNTY DHS ADAMS COUNTY COUNTY OF WELD 900 JEFFERSON PARKWAY 4430 S ADAMS CO PKWY 1150 O STREET 4TH FLOOR C 4000A BRIGHTON CO 80601 GOLDEN CO 80401 This Certificate Issued to: Name: COLLABORATIVE SERVICES FOR CHANGE PC Address: 2480 W 26TH AVE STE 130B GREE CO 80631 Aut orized Representative DENVER CO 80211 APA 00138 00 (06/2014) ACORO® CERTIFICATE OF LIABILITY INSURANCE `------ DATE(MMmDrevyY) 04/23/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Dodrill Insurance, Inc. PO BOX 27299 Lakewood, CO 80227 CONTACT NAME: Roxanne Martinez NE IA/C. No Ext): (303)986-1539 I ac. No): (303)989-8755 A oRESS: roxanne@dodrillinsurance.com INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A: Amco Insurance Company 19100 INSURED Collaborative Services for Change PC 2480 W 26th Ave Ste 130B Denver, CO 80211-5327 INSURER B: Plnnacol Assurance INSURER C : INSURER D : INSURER E: INSURER F : - COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 16 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL !MDWVD SUBR POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DDIYYYYI UNITS A X COMMERCIAL GENERAL LIABILITY ACPBPO7531648867 09/04/2017 09/04/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMISES Ea occu a noel $ 300,000 I CLAIMS -MADE OCCUR MED EXP (Any one person) $ 1,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES ECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILELU1BILm _ X ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY X SCHEDULED AUTOS NON -OWNED AUTOS ONLY ACPBPO7521648867 09/04/2017 DSINGLELIMIT CMBINE09/04/2016 aaccident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ at B WORKERS COMPENSATION AND EMPLOYERS' UABILITr YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below N / A 4191112 04/01/2018 04/01/2019 X I STATUTE I I ER E.L. EACH ACCIDENT S 100,000 E.L. DISEASE - EA EMPLOYEE S 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 11 more. space Is required) CERTIFICATE HOLDER CANCELLATION County of Weld 1150 O Street Greeley, CO 80632 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A RIZED REPRESENTATIVE ACORD 25 (2016/03) (RIM) © 1988-2015 ACORD CORPORATIQTN All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by,RIM on April 23, 2018 at 12:21PM Date: Post -Annual Proposal Checklist (For use by Child Welfare) ** Checklist must be completed and submitted with the proposal documents when requesting a contract. ** 1./)(e a Checklist Completed By: 1)0/ . 'Gv! n ( Gvi Vendor (Legal Name): �� ll a .b wet Ave Extension: O10 SP./ace..r CAGn1G fic / Proposed Services: 1. /1171-cAr-iYI r_ 2. 1171 /mar 4-ss..ski NG,' 4,1,7'7 (Highlight Services 0 Approved for Contract) 3. 4. S. 6. 7. 8. 9. 10. Approved Funding Source (Circle One): Case CW Admin Other: Signature Authority: Full Name: /1/4-4(Ci dote WC'✓ Title: C6 -llkiner e i4, ra Email: /'116rewere C.CC Solver. co -w? Phone Number: 5 0J - Yr; -6/46— Verify each required document is fully completed and attache o Introduction Letter'^ 4K —Provider Information Form (PIF) ll • Completed Proposal Template (For each .ro.osed se/vi.,;" U''P' t /�,/1 ca ---Completed Staff Data Sheet (For each proposed service) o Current Certificate of Insurance (COI) with Weld County listed on-the..CO1-'as an Additional Insured OR a Letter of Intent from an insurance company authorized to do business in the State of Colorado stating•its willingness to insure the bidder pursuant to the terms of the of the Request for Bid. Most commonly missed services/rates*: o Intake o Staffing (Court Facilitation/Court Staffing/Family Team Meeting/Team Decision Making Meeting) o Multidisciplinary Team (MDT) o Partial Home Study (Home Studies only) o Additional Adult — beyond two adults (Home Studies only) o Radius (Transportation or Mileage) *NOTE: These may not always be applicable to the service(s) being proposed. 2480 West 26'" Avenue, Suite 130-8 • Denver, CO 80211 • Phone: 303-433-0188 • Fax: 303-433-6145 4-30-19 To Whom It May Concern: This letter is to serve as a formal bid to Weld County Department of Human Services for Collaborative Services for Change, PC to continue providing services for the upcoming 2019-20 fiscal year. This bid is specifically for providing Mentoring Services, a new service being offered. Collaborative Services for Change, PC is a private S -Corporation with two owners, Marci Brewer, LCSW and Jeff Kisicki, LCSW, in addition to two full-time employees, Matt Mock, MSW and Matt Moore, BS. Collaborative Services for Change, PC is committed to providing services to individuals, couples, families and youth, working to improve the quality of their relationships and ability to realize their full potential in daily functioning. Through a collaborative, culturally sensitive and holistic approach, we design personalized treatment plans, offering particular expertise in the areas of promoting healthy relationships, recovery from trauma and/or victimization, sexual abuse treatment, issues related to stress management, depression and anxiety, and supporting the development of life skills and behavior management for those with special needs. Our practice is centrally located in Denver, Colorado, in close proximity to 125, Rt. 6, and along the RTD Bus Routes. Current contact information is noted on the above letterhead, serving as both our physical address and our mailing address. Collaborative Services is not a Medicaid Provider. Therapeutic Mentoring Services may be directly provided by Matt Mock, MSW or Matt Moore, BS while under the supervision of Marci Brewer, LCSW. Matt Moore, BS has approximately four years' experience providing counseling, case management and consultation, and mentoring services with both juveniles and adults. Matt Mock, MSW has provided counseling and mentoring services since 2007, in addition to his current position as Psychotherapist, offering individual therapy for both adults and juveniles, in addition to his specialty in providing Animal Assisted Therapy, since 2015. Mentoring services are currently being offered to juvenile males who may be residing in either foster care or residential placement, ranging in age from 13-21 years old, with our without developmental disabilities, with our without sexual offense specific needs. Mentoring services are designed to be conducted either in the home or in the community. Mentoring services offered include two specific levels of intervention: 1) Therapeutic Mentoring, and, 2) Therapeutic Mentoring with Animal Assisted Therapy. The goals of said services are to;. • To develop, improve and reinforce community -based functioning and age -appropriate independent living skills. • To establish and maintain community containment while supporting the client to internalize such skills toward improved personal risk management and age appropriate independence. • To strengthen overall boundaries, social skills, communication, problem solving, coping PDF.js viewer . Page 1 of 2 EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Cotlaborarive Services for Chance. PC AGENCY OR PRIVATE PRACTICE 1529913 TRAILS PROVIDER ID (If Known) Mci Brewer. LCSW Co owner, Clinic Dire PRIMARY CONTACT'- FULL NAME ( 303 1433-01B8 PHONE NUMBER tnB re.wzr{ACfeCfe nvM,C^m PRIMARY CONTACT - E-MAIL ADDRESS EXT. 2480 W. 2Gth Ave. Stifle 130-B Denver. Co B.0211 AGENCY MAILING ADDRESS PRIMARY CONTACT - TITLE 1 303 1 n33•Gl45 FAX NUMBER www.cscdenver.com AGENCY/PRACTICE WEB .ADDRESS (IF APPUCABLE) CITY ZIP REFERRAL CONTACT Marcl Brewer. LCSW ABOVE REFFRRAL CONTACT - FULL NAME REFERRAL CONTACT - TITLE 1 1 ' ABOVE REFERRAL CONTACT -PHONE NUMBER ABOVE EXT. REFERRAL CONTACT - E-MAIL ADDRESS BILLING CONTACT Marc' Brewer, LCSW ABOVE BILLING CONTACT - f ULL NAME BILLING CONTACT - TITLE ABOVE ABOVE BILLING CONTACT - PHONE NUMBER EX'r. BILLING CONTACT - E-MAIL ADDRESS 'certify that the services proposed for intended use by the Weld County Department of Human Services wil all the specifications it has so indicated in this bid form 1 further affirm iutentiou to enter into all agreemen Weld County, on behalf of the Weld County Department of Human Services, and comply with all requiem( the contract, if awarded. The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any iuformall 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 Bo of the County of Weld, State of Colorado. The Boatel of Weld Cotunty Commissioners shall give preference resident Weld County bidders in all cases where the bids are competitive in price and quality. Signature of Authorized Representative: Marci Brewer,. LCSW n-.r....F c 1,,....•. •.e• n 1.01 10 https://secure.virtru.com/viewer 4/26/2019 PDF.js viewer Page 1 of 4 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: 2. Program name or service type being proposed: Collaborative Services for Change, PC Mentoring 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. This service is intended to be conducted either in the home or in the community, thus mi entail individual counseling with healthy life skill development. In doing so, curriculum or include, but not be limited to, developing and strengthening community -based functionii healthy boundaries, communication, problem solving skills, coping strategies and overall development. Animal -assisted Therapy (AAT) would be specifically provided for interested individuals, f initial intake meeting focused on the client's historical and current interactions with anirr will assess for suitability and any possible counter -indications for AAT. AAT will assist clie developing communication skills, pro -social community interactions, reading non-verbal language, establishing and maintaining boundaries, building empathy and developing ski consent. Clinician, Matt Mock, MSW, owns a registered professional therapy dog certifies Freedom Service Dogs of America, named Bonnie. Bonnie's health, welfare and medical r constantly monitored, although her inclusion in services may be contingent on other fact 4. Capacity to Provide Services (ex. 4 hours/week). Capacity may vary per client needs; however, general expectation would entail 2-4 hours Monday through Friday. Client contact may include face -face, telephone consultation ant deemed appropriate by the Multi -disciplinary Team. 5. Goals of the service. • To develop, improve and reinforce community -based functioning and age-appro� independent living skills. e To establish and maintain community containment while supporting the client to such skills toward improved personal risk management and age appropriate indel • To strengthen overall boundaries, social skills, communication, problem solving, c strategies, empathy skills and the development of self-esteem and positive self -in 6. Outcomes of service. o Clients may evidence improved mood, motivation and contained access to the co when other familial supports may not be available. https://secure.virtru.com/viewer 4/26/2019 PDF.js viewer Page 3 of 4 EXHIBIT C PROPOSAL TEMPLATE • Clients may demonstrate improved mastery managing boundaries, evidencing col safety, problem solving skills and coping with both internal and external stressors decreasing risk and increasing age appropriate community -based functioning. 7. Target population for service. Note: Please include age range, applicable genders, and any specific characteristics/trait Target population includes males residing in foster or group home placements, ranging it 21 years old, with or without developmental disabilities, with or without sexual offense s Any clientele referred should be able to evidence a baseline of safety and compliance. Ar history of making false allegations or overt staff assault may be a counter -indication for t 8. Service access. Note: Bidder must indicate capacity for video conferencing, phone conferencing and in pt If office -based, bidder should provide full physical addresses for all locations. If provided office, bidder should note home -based and/or community -based, and geographical area( willing to travel to. As service is intended to be home -based and/or community -based, travel will be within area of 30 minutes travel time from the office, located at 2480 W. 26th Ave, Suite 130-B [ 80211. It is expected that the client may meet the provider at a community location, or Providers will not be able to directly transport clients in their personal vehicles. 9. Languages service is available in. Note: Bidder should note the language and level of proficiency. English only. 10. Rates of service. Note: Bidder should include fee for service, staffing, mileage, and any other applicable cc would like considered. Rates must be an exact amount and must include the unit of cost month, episode). Approximate rates or a range of rates for a service will not be accepted MENTORING SERVICE: • $65.00 per direct client contact hour, be that face -face, telephone or digital mea, communication. MENTORING WITH ANIMAL ASSISTED THERAPY: • $100 per direct client contact hour, be that face -face, telephone or digital means communication. TRAVEL WITHIN CATCHMENT AREA OF A 30 MIN. DISTANCE FROM OFFICE, ROUND TRIP: • Rate +1/2 (i.e.: 65 + 32.50 = 97.50) • Any services delivered beyond catchment area include mileage reimbursement of mile. https://secure.virtru.com/viewer 4/26/2019 PDF.js viewer Page 1 of 2 STAFF DATA SHEET EXHII (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff D PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: .. APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION No. Last Name . First Name Warkt4 Work Email Education Level 1 , Degree Focus r 1 Mock Matt 3-433-0188 mmock@cscdenver.com 2 MSW Social Work 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Sid No.: B1900025 https://secure.virtru.com/viewer 4/26/2019 PDF.js viewer Page 1 of l STAFF DATA SHEET EXHII (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Statt GI PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: _ _ ';. _" .: ,<.� ,... ... ' :APPLICABLE STAFF,„MEMBER OR CONTRACTOR INFORMATION ,j No. Last Name . I First Name, -' . ` - : Work#. , Work Email .- Education Level - . - ,'� Degree Focus 1 Kisicki Jeff 3-433-0188 jkisicki@cscdenver.com 2 MSW Social Work 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 2'7 . 28 Bid No.: 81900025 https://secure.virtru.com/viewer 4/26/2019 • PDF.js viewer Page 1 of 1 STAFF DATA SHEET EXHII (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff D PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: " APPLICABLE STAFF MEMBER OR:CONTRACTOR INFORMATION . No: Last Name ' Fitst Name ,,. ` . World! - Work Email , Education level, • , ' Degree Focus i 1 Brewer Marci 3-433-0188 mbrewer6Dcscdenver.com 2 MSW Social Work 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Bid No.: 81900025 https://secure.virtru.com/viewer 4/26/2019 PDP.js viewer Page 1 of 2 STAFF DATA SHEET EXH11 (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff D PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: ..... _,APPUCABLE STAFF MEMBER OR CONTRACTOR'.INFORMOION _- ' No. Last Name First :Name . Wor:0 1 - _ Work Email Education Level ;_ Degree FOCUS 1 1 Moore Matt 3-433-0188 mmoore@cscdenver.c4m 2 BS Psychology 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Bid No.: 81900025 https://secure.virtru.com/viewer 4/26/2019 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provider Mental Health Services, Sexual Abuse Treatment (Offense Specific), and Mentoring, as referred by the Department. 2. Mental Health Services: a. Services available under this agreement include: i. Individual Therapy ii. Family Therapy iii. Eye Movement Desensitization and Reprocessing (EMDR) Therapy iv. Healthy Sexuality/Boundaries Curriculum b. Contractor utilizes the following in the delivery of services: i. Cognitive Behavioral Therapy ii. Family Systems Therapy iii. Trauma Recovery iv. Eye Movement Desensitization and Reprocessing (EMDR) Therapy c. Capacity for Services: Varies, 1-10 hours per week d. Goals of Service: i. Improved client mental health ii. Assist the client in understanding how their mental health impacts their functioning iii. Help client identify triggers and stressors that impact their mental health iv. Help the client develop and utilize strategies for mental health management v. Address child welfare specific needs such as the consequences of loss and grief, abuse and neglect, and resiliency e. Outcomes of Service: i. Client will experience psychological safety within the context of the therapeutic relationship ii. Client will experience improvements in the following areas: 1. Self-observation skills 2. Cognitive insight 3. Cognitive restructuring skills 4. Emotional recognition 5. Increased emotional self -regulation 6. Awareness of behavioral functioning (both past and present) 7. Recognition of harm done,, if applicable 8. Coping strategies for overall behavioral regulation 9. Relationships 10. Decreased risk 11. Increased health and resiliency 12. Overall improved functioning iii. Target Population: 1. Individual youth, 10-21 years of age 2. Families/couples 3. Team members 4. Developmentally disabled iv. Service Access: 1. In office: 2480 West 26`h Avenue, Suite 130-B, Denver, CO 80211 2. Phone conferencing (no video conferencing) 1 3. In community: Conducted in the home, school, Department or courthouse as necessary and dependent upon Contractor's availability. Travel time will be included in the service billed. v. Language: English only. 3. Sexual Abuse Treatment (Offense Specific Treatment): All services will be provided in compliance with Sex Offender Management Board (SOME) standards. a. Services available under this agreement include: i. Individual Therapy ii. Family Therapy iii. Eye Movement Desensitization and Reprocessing (EMDR) Therapy iv. Healthy Sexuality/Boundaries Curriculum v. Informed Supervision Trainings b. Contractor utilizes the following in the delivery of services: i. Cognitive Behavioral Therapy ii: Family Systems Therapy iii. Trauma Recovery iv. Eye Movement Desensitization and Reprocessing (EMDR) Therapy v. Colorado Sex Offender Management Board (SOMB) Juvenile Standards c. Capacity for Services: Varies, 1-10 hours per week d. Goals of Service: i. Address issues and behaviors related to sexual abuse victimization, sexual dysfunction, and sexual abuse perpetration ii. Prevent further sexual abuse and victimization iii. Psycho -education for parents regarding victim and perpetrator issues such as clarification and reunification, family therapy, informed supervision, safety planning, and general boundaries e. Outcomes of Service: i. Client will experience psychological safety within the context of the therapeutic relationship ii. Client will experience improvements in the following areas: 1. Self-observation skills 2. Cognitive insight 3. Cognitive restructuring skills 4. Emotional recognition 5. Increased emotional self -regulation 6. Awareness of behavioral functioning (both past and present) 7. Recognition of harm done, if applicable 8. Coping strategies for overall behavioral regulation 9. Relationships 10. Decreased risk 11. Increased health and resiliency 12. Overall improved functioning iii. Target Population: 1. Individual youth, 10-21 years of age 2. Families/couples 3. Containment or MDT Members/Informed Supervisors 4. Developmentally disabled 2 iv. Service Access: 1. In office: 2480 West 26`x' Avenue, Suite 130-B, Denver, CO 80211 2. Phone conferencing (no video conferencing) 3. In community: Conducted in the home, school, Department or courthouse as necessary and dependent upon Contractor's availability. Travel time will be included in the service billed. v. Language: English only. 4. Mentoring a. Services available under this agreement include: i. In -home or in the community and will include individual counseling with healthy life skill development. Services will include but are not limited to developing and strengthening community -based functioning, healthy boundaries, communication, problem solving skills, coping strategies and overall development. ii. Animal -assisted Therapy (AAT) as appropriate for interested individuals. AAT will assist indidivduals in developing community skills, po-social community interactions, reading non-verbal language, establishing and maintaining boundaries, building empathy and developing skills. b. Capacity for Services: Varies, two (2) to four (4) hours per Monday through Friday. Client contact may include face-to-face and telephone consultation as deemed appropriate by the Multi -disciplinary Team (MDT). c. Goals of Service: i. To develop, improve and reinforce community -based functioning and age -appropriate independent living skills. ii. To establish and maintain community containment while supporting the client to develop such skills toward improved personal risk management and age appropriate independence. iii. To strengthen overall boundaries, social skills, communication, problem solving, coping strategies, empathy skills and the development of self-esteem. d. Outcomes of Service: i. Improved mood and contained access to the community when other familial supports may not be available. ii. Improved skill development to navigate community -based age -appropriate life skills including, but not limited to, learning how to navigate transportation, retail transactions, pro= social recreational and cultural activities, general public interactions and safety. iii. Improved mastery managing boundaries, evidencing safety, problem solving skill sand coping with both internal and external stressors. iv. Decreased risk and increased age -appropriate community -based functioning. e. Target Population: Male youth residing in foster or group home placements, up to age 21 years of age, with or without developmental disability, with or without sexual offenses. A baseline of safety and compliance should be evidenced. Any youth with a history of making false allegations or overt staff assault may not be appropriate. 3 f. Service Access: Contractor will travel within 30 minutes of travel time from 2480 West 26`x' Avenue, Suite 130-B, Denver, CO, 80211. Contractor will meet clients at an agreed upon community location but will not transports clients. g. Language: English only. 5. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 6. 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). 7. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. After three (3) "no-shows, "Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210): 8. 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. 9. 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. 10. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 11. 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. 12. 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, 4 change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 13. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as the meeting is at least one hour in length, the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 14. Contractor will notify the Quality Assurance Team Supervisor (hainleid@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. 5 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 Mental Health Services $85.00/Hour (Case Management) $120.00/Episode (EMDR — 90 -minute Session) $100.00/Hour (Family Session, 50 -minute Session) $100.00/Hour (Healthy Sexuality/Boundaries Curriculum — 50 -minute Session) $100.00/Hour (Individual Session, 50 -minute Session) $85.00/Hour (Team Meetings or Staffing, 50 -minute Session) Sexual Abuse Treatment $85.00/Hour (Case Management) $120.00/Episode (EMDR — 90 -minute Session) $100.00/Hour (Family Session, 50 -minute Session) $100.00/Hour (Healthy Sexuality/Boundaries Curriculum — 50 -minute Session) $100.00/Hour (Individual Therapy, 50 -minute Session) $100.00/Hour (Informed Supervision Training, 50 -minute Session) $85.00/Hour (MDT, Team Meetings or Staffing, 50 -minute Session) Mentoring $65.00/Hour (Mentoring, direct client contact — Face -to -Face, telephone or digital means communication) $100.00/Hour (Mentoring with Animal -assisted Therapy (AAT), direct client contact — Face-to-face, telephone or digital means communication) Mileage Catchment — Hourly rate plus half within the first 30 miles. $.56/Mile (Each additional mile beyond 301 -r -flies. 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 rh day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. Contract Form New Contract Request Entity Information Entity Name* COLLABORATIVE SERVICES FOR CHANGE PC Entity ID* W{1037136 1'6 Contract Name* COLLABORATIVE SERVICES FOR CHANGE PC {AGREEMENT AMENDMENT) Contract Status CTB REVIEV,? Contract ID 2918 Contract Lead* CULLINTA ❑ New Entity? Parent Contract ID 20192018 Requires Board Approval YES Contract Lead Email Department Project # cullinta@co weld co us Contract Description* AGREEMENT AMENDMENT TO EXISTING AGREMEENT FOR SERVICES. CONSENT AGENDA. Contract Description 2 Contract Type* AGREEMENT Amount* S0.00 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServicesPvi eldq©v com Department Head Email C hrt-HumanSerli c es- DeptHead(rrDweldgo: corn County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYAORNEY@btiELD `SOV CUM Requested BOCC Agenda Date* 07/1012019 Due Date 07/06,i2G19 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* Renewal Date G4i'Cl 1:2020 Termination Notice Period Committed Defive Date Expiration Date* 0S131.=2020 Contact Information Contact Info Contact Name Purchasing Purchasing Approver Approval Process Department Head JUDY GRIEGO DH Approved Date D7/1912019 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date Oa/28/2019 Originator CULLINTA. Contact Type Contact Email Finance Approver BARB CONNOLLY Contact Phone 1 Contact Phone 2 Purchasing Approved Date Finance Approved Date 07'22,2019 Tyler Ref #F AG 082819 Legal Counsel ROBIN COCHRAN Legal Counsel Approved Date 07/22+2019 Submit CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND COLLABORATIVE SERVICES FOR CHANGE, PC This Agreement, made and entered into tday of Weld County Commissioners, on behalf of the Weld County Department as the "Department' and Collaborative Services for Change, PC hereinaft 2019 by and between the Board of uman Services, hereinafter referred to 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 Mental Health Services and Sexual Abuse Treatment. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 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 Proposal and Exhibit C, Scope of Services. 3. Referrals, Billing and Tracking a. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e- mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-X6210). 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 7`h of the month, following the month of service, utilizing billing forms required by the cam: adb- 64-‘0) 2019-2018 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 7`h 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. Pavment 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 indudes 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. sec .. 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 govem 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. §&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, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Contractor shall provide the liability insurances (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged in the performance of this Agreement which are required under Weld County's Request for Proposal, and required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the acceptable evidence that such coverage is in effect within seven (7) days of the date of this Agreement. At a minimum, Contractor shall procure, either personally or through its employer as applicable to the Contractor's business, at its own expense, and maintain for the duration of the work, 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 duning 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 disa-etion. 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 Marci Brewer, Clinical 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: Marci Brewer, Clinical Director 2480 West 26th Avenue, Suite 130-B Denver, CO 80211 (303) 433-0188 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, B, 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 §2450-507 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: S�.drAirA) sieL;li BOARD OF COUNTY COMMISSIONERS Weld Co Clerk to the Board WELD COUNTY, COLORAD By: Deputy Clerk to t 15 Barbara Kirkmeyer, CONTRACTOR: r MAY Collaborative Services for Change, PC 2480 West 266' Avenue, Suite 130-6 Denver, CO 80211 (303) 433-0188 �i 2we, Lariv Marci Brewer, LCSW (May 7, 2019) By: Date: ca 2019 Marci Brewer, Clinical Director May 7, 2019 O2o/ 9 -02.01 f 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 lOtiVe s. 2480 West 26"' Avenue, Suite 130-8 • Denver, CO 80211 • Phone: 303-433-0188 • Fax: 303-433-6145 1-21-19 To Whom It May Concern: This letter is to serve as a formal bid to Weld County Department of Human Services for Marci Brewer, LCSW to continue providing services for the upcoming 2019-20 fiscal year. Collaborative Services for Change, PC is a private S -Corporation with two owners, Marci Brewer, LCSW and Jeff Kisicki, LCSW. This contract for services is specifically for Marci Brewer, LCSW as a service provider. Collaborative Services for Change is committed to providing services to individuals, couples, families and youth, working to improve the quality of their relationships and ability to realize their full potential in daily functioning. Through a collaborative, culturally sensitive and holistic approach, we design personalized treatment plans, offering particular expertise in the areas of promoting healthy relationships, recovery from trauma and/or victimization, sexual abuse treatment, issues related to stress management, depression and anxiety, and supporting the development of life skills and behavior management for those with special needs. Our practice is centrally located in Denver, Colorado, in close proximity to 125, Rt. 6, and along the RTD Bus Routes. Current contact information is noted on the above letterhead, serving as both our physical address and our mailing address. Collaborative Services is not a Medicaid Provider. As the attached resume will detail, this clinician offers over 26 years' experience as a Licensed Clinical Social Worker with evidenced capacity to deliver quality services as identified in Exhibit A_ Said services have been evidenced for WCDHS, having been a long standing provider, as well as services being conducted in a myriad of environments throughout this clinician's professional experience. In addition, this clinician is CO SOMB (Sex Offender Management Board) approved (since its inception 2002) as a Full Operating Treatment Provider, including a specialty in treating those with Developmental Delays. Proof of this inclusion with the SOME can be found on their website, on the provider listings. Moreover, this clinician is trained in EMDR (Eye Movement Desensitization and Reprocessing) Therapy, Levels I and II. Thus, both specific training and many years of successful clinical experience are evidenced as expertise in the field. Referrals may be presented to Marci Brewer, LCSW via email or phone. Responses to confirm recognition and/or acceptance of said referral will be sent within 48 business hours. Past contracting and working agreements may serve as further evidence of this clinician's responsiveness to referrals and related quality of services provided. Please see the attached materials. Thank you for this opportunity to continue our work with WCDHS. Respectfully submitted, Marci Brewer, LCSW EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Collaborative Services for Change. PC 19165 AGENCY OR PRIVATE PRACTICE TRAILS PROVIDER ID (If Known) Marci Brewer. LCSW PRIMARY CONTACT - FULL NAME ( 303 1 433-0188 PHONE NUMBER mbnewerfOcollaborativeservices4chanee.com PRIMARY CONTACT- E-MAIL ADDRESS 2480 W. 26th Ave Suite 130-8 AGENCY MAILING ADDRESS EXT. Clinical Director PRIMARY CONTACT - TITLE f 303 D 433-0145 FAX NUMBER AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) Denver CITY 80211 ZIP Marci Brewer. LCSW REFFERAL CONTACT -FULL NAME SAME � B SAME REFERRAL CONTACT- PHONE NUMBER REFERRAL CONrAcr EXT. SAME REFERRAL CONTACT -TITLE SAME REFERRAL CONTACT- EMAIL ADDRESS Marti Brewer. LCSW BIW NG CONTACT - FULL NAME ( 1 SAME BIWNG CONTACT -PHONE NUMBER BIWNG CONTACT SAME 81 WNG CONTACT - TITLE SAME EDIT. 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: Marci Brewer, LCSW Date of Signature: 1-21-19 _ Bid No.: B1900025 EXHIBIT C PROPOSAL TEMPLATE I. Bidder's legal entity name: 2. Program name or service type being proposed: Collaborative Services for Change, PC Mental Health Treatment 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. MODALITIES: Individual Therapy Family Therapy EMDR (Eye Movement Desensitization and Reprocessing) Therapy Healthy Sexuality/Boundaries Curriculum Staffings Case management Court Testimony as needed CURRICULUM, TOOLS, CLINICAL FRAMEWORK: Cognitive Behavioral Therapy Family Systems Therapy Trauma Recovery EMDR (Eye Movement Desensitization and Reprocessing) Therapy 4. Capacity to Provide Services (ex. 4 hours/week). Varies, from 1-10 hours/week 6. Goals of the service. Per the WCDHS definition of service, this clinician concurs: Mental Health service should improve the clients' mental health, assist the client in understanding how their mental health impacts their functioning, help identify triggers and stressors that impact their mental health, and help the client develop and utilize strategies for mental health management. Interventions should address child welfare specific needs such as the consequences of loss and grief, and abuse and neglect, and assist in building resiliency. 6. Outcomes of service. Within the context of a therapeutic relationship the client should experience psychological safety while gaining improved self-observation skills, cognitive insight, cognitive restructuring skills, emotional recognition, increased emotional self -regulation, awareness of behavioral functioning (both past and present), recognition of harm done (if applicable), improved coping strategies for overall behavioral regulation, improved relationships, in addition to decreased risk and increased health and resiliency toward overall improved functioning. 7. Target population for service. Individual Youth 10-21YOA; Families/Couples; Team Members. Specialty services designed for the Developmentally Disabled are available as needed. 8. Service access. In office services: 2480 W. 26th Ave, Suite130-B Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE Denver, CO 80211 303-433-0188 Phone conferencing available; no capacity for video conferencing Community based services, such as Stallings, may be conducted in the home, school, WCDHS or courthouse as is necessary and upon this clinician's availability. Travel time will be included in the service billed. 9. Languages service is available in. English only 10. Rates of service. ***remised 2-25-19 Rates: a. Individual Therapy b. Family Therapy c. EMDR Therapy Session d. Staffing/MDT/FTM e. Case Management Services 15min increments as needed) f. Healthy Sexuality/Boundaries Curriculum $100.00 per 50 min hour g. Court Testimony $100.00 per 50 min hour h. Travel time, if applicable, will be added to the service delivered at that rate Bid No.: 1900025 $100.00 per 50 min hour $100.00 ,per 50 min hour $120.00 per 90 minute session $85.00 per 50 min hour $85.00 per 60 min hour (to be billed in EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: 2. Program name or service type being proposed: Collaborative Services for Change, PC Sexual Abuse Treatment 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. MODALITIES: Individual Therapy Family Therapy EMDR (Eye Movement Desensitization and Reprocessing) Therapy Healthy Sexuality/Boundaries Curriculum Informed Supervision Trainings Staffings Case management Court Testimony as needed CURRICULUM, TOOLS, CLINICAL FRAMEWORK: Cognitive Behavioral Therapy Family Systems Therapy Trauma Recovery EMDR (Eye Movement Desensitization and Reprocessing) Therapy Colorado Sex Offender Management Board Juvenile Standards 4. Capacity to Provide Services (ex. 4 hours/week). Varies, from 1-10 hours/week 5. Goals of the service. Per the WCDHS definition of service, this dinician concurs: Therapeutic intervention designed to address issues and behaviors related to sexual abuse victimization, sexual dysfunction, sexual abuse perpetration, and to prevent further sexual abuse and victimization. It is expected that for criminal sex abuse cases, the provider will attend Multi -Disciplinary Team Meetings to provide input, insight and guidance into progress, safety planning, and next steps. Psycho -education for parents re: victim and perpetrator issues such as clarification and reunification, family therapy, informed supervision, safety planning, and general boundaries. 6. Outcomes of service. Within the context of a therapeutic relationship the client should experience psychological safety while gaining improved self-observation skills, cognitive insight, cognitive restructuring skills, emotional recognition, increased emotional self -regulation, awareness of behavioral functioning (both past and present), recognition of harm done (if applicable), improved coping strategies for overall behavioral regulation, improved relationships, in addition to decreased risk and increased health and resiliency toward overall improved functioning. 7. Target population for service. Individual Youth 10-21YOA; Families/Couples; Containment or MDT Members/Informed Supervisors. Specialty services designed for the Developmentally Disabled are available as needed. Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE 8. Service access. In office services: 2480 W. 26"' Ave, Suite130-B Denver, CO 80211 303-433-0188 Phone conferencing available; no capacity for video conferencing Community based services, such as MDT Staffings, may be conducted in the home, school, WCDHS or courthouse as is necessary and upon this clinician's availability. Travel time will be included in the service billed. 9. Languages service is available in. English only 10. Rates of service. ***revised 2-25-19 Rates: a. Individual Therapy b. Family Therapy c. EMDR Therapy Session d. Staffing/MDT/FTM e. Case Management Services min increments as needed f. Informed Supervision Training $100.00 per 50 min hour g. Healthy Sexuality/Boundaries Curriculum $100.00 per 50 min hour h. Court Testimony $100.00 per 50 min hour i. Travel time, if applicable, will be added to the service delivered at that rate Bid No.: 1900025 $100.00 per 50 min hour $100.00 per 50 min hour $120.00 per 90 minute session $85.00 per 50 min hour $85.00 per 60 min hour (to be billed in 15 STAFF DATA SHEET Bidder must list all applicable staff who wiD manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not combine services.) , - PROPOSED SERVICE OR SERVICE TYPE: Health Treatment retrial Collaborative Services for Change APPLICABLE STAFF MESME t OR CONTRACTOR O FORPAATION • " SUPERVISOR INFORl6ATION No: fast Name .' First. Name _ ' : World, .- Work Emarl � Education level � Degree Focus. Licensors/ Credentials DORA V . (if applicable) _' - last Name - Fast Name - Work O . Work Email - 1 Brewer Marci 303333-0188 mbrewertacolkborativeservices4change.com ' 2 3 Master's Social Work LCSW 991181 N/A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 EXHIBIT D Bid No.: 81900025 STAFF DATA SHEET (Bidder must list a0 appfcable staff who will manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not cond i:re services.) PROPOSED SERVICE OR SERVICE TYPE: exual Abuse Treatment BIDDER LEGAL ENTITY NAME: laboratve Services for Change . - APFIlCABIE STAN MEMBER OR CONTRACTOR OtTORMATION ' SUPERVISOR INFORMATION _ No. Last Name First Name Wolof ' Work Email Education Loved - Degree Focus liaerwae/ Credentiab D05tA0 . (ff apppotpb) fast Name First Name , c Work A Work Email ' 1 Brewer Marl 303433-0188 mbrewerPcollaborativeservices4chanee.com 2 3 Master's Social Work LCSW 991181 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 EXHIBIT O Bid No.: 81900025 MARCI M. BREWER, LCSW EDUCATION Post -Graduate Clinical Training, September 1993 - September 1995 Colorado Institute for Marriage and the Family, Boulder, Colorado Master of Social Work, June 1991 University of Denver, Denver, Colorado Bachelor of Science in Social Work, May 1987 Bowling Green State University, Bowling Green, Ohio CREDENTIALS Licensed Clinical Social Worker Colorado License Number 991181, October 1993 Approved Juvenile Full -Operating Treatment Provider, with Developmental Disability Specialty, and Full -Operating Evaluator, via the Colorado Sex Offender Management Board, 2002 to present EMDR (Eye Movement Desensitization and Reprocessing) Trained: Level I and II, May 2012 EXPERIENCE Collaborative Services for Change, PC, Denver, Colorado Clinical Director and Co-owner, June 2004 to present • Provide outpatient mental health therapy for individuals, couples, youth and families focusing on a variety of presenting issues, utilizing a strength based, systemic and cognitive behavioral approach including: o Recovery from sexual victimization o Trauma recovery o Family issues and Parenting o Relationship improvement o Anger management o Behavior disorders o Mood disorders o Issues with stress, anxiety and/or affect regulation o Life stage transitions o Social skills intervention o Teen parenting education • Provide EMDR (Eye Movement Desensitization and Reprocessing ) Therapy • Develop and implement outpatient treatment programming that is sexual offense specific for juveniles, including the following services: o Offense specific evaluations o Intake assessments o Individualized treatment planning o Treatment for special needs youth, developmentally disabled youth and those with dual diagnoses who have evidenced sexually abusive acting out o Individual, group, and family therapy o Field therapy Marci M. Brewer, LCSW Page 2 o Polygraph preparation o Healthy sexuality and boundaries curriculum o Informed supervision trainings o Case management, stuffings and court testimony as needed • Provide holistic mental health treatment programming for special needs, developmentally disabled youth, and those with dual diagnoses • Economic Offender Programming via Denver County Adult Probation 2004 -2018 o Program development o Implement group and individual therapy services • Provide on -site program consultation and foster parent training • Provide professional trainings The [University of Denver Graduate School of Social Work Adjunct Professor, January 2012 • Taught graduate level course in: Cognitive Approaches to Social Work Practice Winter Quarter 2012 • Developed and designed curriculum for coursework • Facilitated an engaging learning environment and administered related assignments • Conducted student evaluation and grading The Resource Center for High Risk Youth, Denver, Colorado Clinical Supervisor, January 2003 — June 2004 Clinician, May 1999 — January 2003 • Completed sexual offense specific evaluations and risk assessments for juveniles • Completed thorough intake assessments for admission and developed personalized treatment plans • Provided outpatient, sexual offense specific family, individual and group therapy with both male and female clients of all ages, based upon the philosophy of Containment Theory • Facilitated containment staffings with related case management, report writing and court testimony as needed • Created and co -facilitated a Multi -family Group • Created and presented a bi-monthly psycho -education class on Informed Supervision and Therapeutic Care • Supervised clinicians and MSW Student Intern(s) • Assisted in administrative duties and agency program development Private Practice, August 1993 — June 2004 • Private practice on a part-time basis, conducting individual, family, marital and group therapy to a variety of outpatient clientele (2002 - 2004) • Conducted contract work with Therapeutic Alliance, including individual, family and group therapy (2001 - 2004) • Conducted a six week Foster Parent Training seminar for Denver Area Youth Services (1997) • Facilitated a parent support group under contract for the Denver Family Therapy Center (1993) Marci M. Brewer, LCSW Page 3 Shiloh House, Inc., Littleton, Colorado Clinician, February 1997 — May 1999 • Provided family, group and individual therapy, within a continuum of residential, day treatment, in -home and community -based settings • Effective intervention with high risk clientele, including such populations as sexual offense specific, juvenile delinquency and emotionally disturbed children and adolescents • Conducted sexual offense specific evaluations and court reports • Performed ongoing assessment, case coordination and multidisciplinary treatment planning • Facilitated a Multi -family Group • Conducted crisis intervention and behavior management for the programs, and clinical training for the staff Colorado Christian Home, Denver, Colorado Residential Unit Supervisor, April 1995 - December 1996 • Managed a residential treatment unit for severely traumatized children and their families • Facilitated individual and group supervision for a clinical staff of 18 • Provided family, group, and individual therapy with related case management • Created innovative residential programming based upon the concept of positive peer culture • Provided ongoing leadership through team process, training, and direct milieu management • Performed rotating emergency clinical supervision of entire residential agency • Responsible for overall operations including hiring, staff development, scheduling, evaluations, and financial budgeting Denver Children's Home, Denver, Colorado Family Therapist, After School and Day Treatment Programs, July 1991 - April 1995 • Assessed intensive outpatient clientele, and developed treatment plans accordingly • Provided family, marital, individual, and group therapy, with court reports and testimony • Coordinated all cases with multiple social agencies and schools • Conducted crisis intervention and behavior management • Supervised MSW Intern Bethesda PsycHealth System, Denver, Colorado Social Work Intern, August 1990 - June 1991 • Conducted family and marital therapy • Co -facilitated a parent support group and a women survivors of sexual abuse group • Presented school in -services Florence Crittenton Services, San Francisco, California Group Counselor, July 1989 - June 1990 • Provided individual counseling, group therapy, crisis intervention and parenting education for adolescent mothers and their children Marci M. Brewer, LCSW Page 4 Sunny Hills Children's Services, San Anselmo, California Residential Counselor, September 1988 - June 1990 • Conducted individual counseling and group therapy for severely disturbed adolescents Henry County Department of Human Services, Napoleon, Ohio Social Services Worker III, January 1987 - May 1988 • Provided counseling and case management services for protective and ongoing caseload • Investigated reports of child abuse, neglect and dependency, including court testimony • Organized and implemented a day care program • Conducted custody and friend of the court investigations • Co -facilitated a therapy group for both survivors and perpetrators of sexual abuse Henry County Court of Common Pleas, Napoleon, Ohio Guardian Ad Litem, December 1987 - May 1988 • Advocated for the best interests of alleged sexually abused children and provided court testimony accordingly CONFERENCES AND PROFESSIONAL TRAIN INGS CONDUCTED • Co -facilitated a sexual offense specific conference for the Department of Youth Corrections (Denver, CO 2000) • Presented three, eight -hour conferences for the Colorado Sex Offender Management Board on: Informed Supervision and Therapeutic Care (2-18-03 Fort Collins, CO; 2-26-03 Colorado Springs, CO and 3-14-03 Grand Junction, CO) • Co -facilitated a 90 -minute conference for the Colorado Child and Adolescent Mental Health Coalition on: Sexually Abusive Youth: A Treatment Framework (3-14-04 Colorado Springs, CO) • Co -facilitated a one -day conference for the Colorado Sex Offender Management Board on: Individualized Treatment Planning and Intervention with Juvenile and Adult Sex Offenders (4-7- 05 Denver, CO) • Co -facilitated a half -day conference sponsored by the Colorado Sex Offender Management Board Victim Advocacy Committee on: Victim Representation on Sex Offender Supervision Teams (10-13-06 Denver, CO) • Provide ongoing Informed Supervision and Therapeutic Care Trainings for multi -disciplinary team members, to present • Presented a professional training for the Colorado Sex Offender Management Board on: Treatment Interventions for Juveniles Who Have Sexually Acted Out (4-28-11 Denver, CO) • Presented a professional training for the Department of Youth Corrections on: Building Victim Awareness: Being Victim Centered, Impacts to Victims, Clarification and Reunification Considerations (3-8-13) PUBLICATIONS • Chapter "Multi -Family Group Therapy for Sexually Abusive Youth" included in the Journal of Aggression, Maltreatment and Trauma, and in the book entitled Identifying and Treating Juvenile Sex Offenders: Current Approaches, Research, and Techniques, Haworth Press, 2004. Account Number: CO COLL 2480 Date: 8/31/18 Initials: LPD GOLDEN CO 80401 This Certificate Issued to: Name: COLLABORATIVE SERVICES FOR CHANGE PC Address: 2480 W 26TH AVE STE 130B CERTIFICATE OF INSURANCE ALLIED WORLD INSURANCE COMPANY C/O: American Professional Agency, Inc. 95 Broadway, Amityville, NY 11701 800-421-6694 This is to certify that the insurance policies specified below have been issued by the company indicated above to the insured named herein and that, subject to their provisions and conditions, such policies afford the coverages indicated insofar as such coverages apply to the occupation or business of the Named Insured(s) as stated. THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE. Name and Address of Named Insured: COLLABORATIVE SERVICES FOR CHANGE PC 2480 W 26TH AVE STE 130B DENVER CO 80211 Additional Named Insureds: JEFF KISICKI MARCI MANDEL BREWER MATT MOCK Type of Work Covered: SOCIAL WORKERS / PROFESSIONAL SOCIAL WORKER Location of Operations: N/A (If different than address listed above) Claim History: None Retroactive date is 09/03/2004 Coverages Policy Number Effective Date Expiration Date Limits of Liability PROFESSIONAL/ LIABILITY 5600-4945 9/03/18 9/03/19 2,000,000 4,000,000 NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED, WHO SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE OF CANCELLATION. Comments: Defense Reimbursement Proceedings Limit is $35,000. 3 ADDL.INS.BELOW: JEFFERSON COUNTY DHS ADAMS COUNTY COUNTY OF WELD 900 JEFFERSON PARKWAY 4430 S ADAMS CO PKWY 1150 O STREET 4TH FLOOR C 4000A BRIGHTON CO 80601 GREE y CO 80631 Aut orized Representative DENVER CO 80211 APA 00138 00 (06/2014) AcoRO® CERTIFICATE OF LIABILITY INSURANCE ki......---- DATE(MMIDDIYYYY) 04/23/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. CONFERS NO RIGHTS UPON THE CERTIFICATE OR ALTER THE COVERAGE AFFORDED BY THE HOLDER. THIS POLICIES AUTHORIZED A CONTRACT BETWEEN THE ISSUING INSURER(S), IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. ff SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Insurance, Inc. PO BOX 27299 Lakewood, CO 80227 CONTACT NAME: Roxanne Martinez PHONDodrill INC. o. Eat (303)986-1539 �.No, (303)989-8755 sum ANNNEESS: roxanne@dodrillinsurance.com INSURER(S) AFFORDING COVERAGE NAIL # INSURER A: Amco Insurance Company 19100 INSURED Collaborative Services for Change PC 2480 W 26th Ave Ste 130B Denver, CO 80211-5327 INSURER a: Pinnacol Assurance INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 00000000-0 REVIS THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. *MR LIR TYPE OF INSURANCE ATM IMO SUER WI/0 POLICY aER IN1B D YYYYY1 EFF EXP POLICY YY1/1 LOOTS A X COMMERCIAL GENERAL LIABiITY ACPBPO7531648867 09104/2017 09/0412018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE I OCCUR _ DAMAGE 10 RENTED PREMISES occurrence) $ 300,000 MED EXP (Any one Pte) $ 1,000 PERSONAL 8 ACV INJURY $ 1,000,000 GERI AGGREGATE LIMIT APPLIES PER: POLICY ERCTT LOC OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS -COMPIOPAGG S 2,000,000 S A AUTOMOBILE _ X LIABILITY ANY AUTO OWNED AUTOS ONLY ERRED AUTOS ONLY _ X SCHEDULED AUTOS NON-OWNEDS AUTOS ONLY ACPBPO7521648867 09/04/2016 09/04/2017 LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODLY INJURY (Per accident) f PROPERTY (DAMAGE S UMBRELLA LIAR EXCESS LAB ,OCCUR CLAMS -MADE EACH OCCURRENCE S AGGREGATE S DED I I RETENTION E S cy B AND JLorCt rm Y IN ION ANY PROPRIETORIPARTNERIEXECUTIVE OFFJCERJMEMBER Flo" MED? Mandalay in NH) IF yes, descriibe under DESCRIPTION OF OPERATIONS below M IA 4191112 04101/209 $ 04/0112019 X I STATUTE I ER E.L EACH ACCIDENT f 100,000 EL DISFO-cE - EA EMPLOYEE 3 100,000 E.L DISEASE - POLICY LIMIT S 500,000 L DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached tt more space is required) CERTIFICATE HOLDER CANCELLATION County of Weld 1150 O Street Greeley, CO 80632 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTNDRIZED REPRESENTATIVE IuW ACORD 25 (2016/03) (RIM) © 1988-2015 ACORD CORP0RATIQN.) All rights reserved. The ACORD name and logo are registered marks of ACORD �J Printed by RIM on April 23, 2018 at 12:21PM EXHIBIT C SCOPE OF SERVICES 1. Contractor will provider Mental Health Services and Sexual Abuse Treatment (Offense Specific), as referred by the Department. 2. Mental Health Services: a. Services available under this agreement include: i. Individual Therapy ii. Family Therapy iii. Eye Movement Desensitization and Reprocessing (EMDR) Therapy iv. Healthy Sexuality/Boundaries Curriculum b. Contractor utilizes the following in the delivery of services: i. Cognitive Behavioral Therapy ii. Family Systems Therapy iii. Trauma Recovery iv. Eye Movement Desensitization and Reprocessing (EMDR) Therapy c. Capacity for Services: Varies, 1-10 hours per week d. Goals of Service: i. Improved client mental health ii. Assist the client in understanding how their mental health impacts their functioning iii. Help client identify triggers and stressors that impact their mental health iv. Help the client develop and utilize strategies for mental health management v. Address child welfare specific needs such as the consequences of loss and grief, abuse and neglect, and resiliency e. Outcomes of Service: i. Client will experience psychological safety within the context of the therapeutic relationship ii. Client will experience improvements in the following areas: 1. Self-observation skills 2. Cognitive insight 3. Cognitive restructuring skills 4. Emotional recognition 5. Increased emotional self -regulation 6. Awareness of behavioral functioning (both past and present) 7. Recognition of harm done, if applicable 8. Coping strategies for overall behavioral regulation 9. Relationships 10. Decreased risk 11. Increased health and resiliency 12. Overall improved functioning iii. Target Population: 1. Individual youth, 10-21 years of age 2. Families/couples 3. Team members 4. Developmentally disabled iv. Service Access: 1. In office: 2480 West 26th Avenue, Suite 130-B, Denver, CO 80211 2. Phone conferencing (no video conferencing) 1 3. In community: Conducted in the home, school, Department or courthouse as necessary and dependent upon Contractor's availability. Travel time will be included in the service billed. v. Language: English only. 3. Sexual Abuse Treatment (Offense Specific Treatment): All services will be provided in compliance with Sex Offender Management Board (SOME) standards. a. Services available under this agreement include: i. Individual Therapy ii. Family Therapy iii. Eye Movement Desensitization and Reprocessing (EMDR) Therapy iv. Healthy Sexuality/Boundaries Curriculum v. Informed Supervision Trainings b. Contractor utilizes the following in the delivery of services: i. Cognitive Behavioral Therapy ii. Family Systems Therapy iii. Trauma Recovery iv. Eye Movement Desensitization and Reprocessing (EMDR) Therapy v. Colorado Sex Offender Management Board (SOMB) Juvenile Standards c. Capacity for Services: Varies, 1-10 hours per week d. Goals of Service: i. Address issues and behaviors related to sexual abuse victimization, sexual dysfunction, and sexual abuse perpetration ii. Prevent further sexual abuse and victimization iii. Psycho -education for parents regarding victim and perpetrator issues such as clarification and reunification, family therapy, informed supervision, safety planning, and general boundaries e. Outcomes of Service: i. Client will experience psychological safety within the context of the therapeutic relationship ii. Client will experience improvements in the following areas: L. Self-observation skills 2. Cognitive insight 3. Cognitive restructuring skills 4. Emotional recognition S. Increased emotional self -regulation 6. Awareness of behavioral functioning (both past and present) 7. Recognition of harm done, if applicable 8. Coping strategies for overall behavioral regulation 9. Relationships 10. Decreased risk 11. Increased health and resiliency 12. Overall improved functioning iii. Target Population: 1. Individual youth, 10-21 years of age 2. Families/couples 3. Containment or MDT Members/Informed Supervisors 4. Developmentally disabled 2 iv. Service Access: 1. In office: 2480 West 26`h Avenue, Suite 130-B, Denver, CO 80211 2. Phone conferencing (no video conferencing) 3. In community: Conducted in the home, school, Department or courthouse as necessary and dependent upon Contractor's availability. Travel time will be included in the service billed. v. Language: English only. 4. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 5. 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). 6. 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 dient per month. After three (3) "no-shows, "Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). 7. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team Supervisor (ha inleid@weldgov.com) immediately via email, to discuss service continuation. 8. 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. 9. 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. 10. 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. 11. 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 3 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. 12. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as the meeting is at least one hour in length, the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 13. Contractor will notify the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-000-6210) 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. 4 EXHIBIT D RATE SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 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 Mental Health Services $85.00/Hour (Case Management) $120.00/Episode (EMDR —90-minute Session) $100.00/Hour (Family Session, 50 -minute Session) $100.00/Hour (Healthy Sexuality/Boundaries Curriculum — 50 -minute Session) $100.00/Hour (Individual Session, 50 -minute Session) $85.00/Hour (Team Meetings or Staffing, 50 -minute Session) Sexual Abuse Treatment $85.00/Hour (Case Management) $120.00/Episode (EMDR — 90 -minute Session) $100:00/Hour (Family Session, 50 -minute Session) $100.00/Hour (Healthy Sexuality/Boundaries Curriculum — 50 -minute Session) $100.00/Hour (Individual Therapy, 50 -minute Session) $100.00/Hour (Informed Supervision Training 50 -minute Session) $85.00/Hour (MDT, Team Meetings or Staffing, 50 -minute Session) 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7"' day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. Hello