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Home My WebLink About20200907.tiffRESOLUTION RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE CHAIR TO SIGN - POLARIS PARTNERS COUNSELING AND CONSULTING, LLC WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Child Protection Agreement for Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Polaris Partners Counseling and Consulting, LLC, commencing December 1, 2019, and ending May 31, 2020, with further terms and conditions being as stated in said agreement, and WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Child Protection Agreement for Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Polaris Partners Counseling and Consulting, LLC, be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 18th day of March, A.D., 2020, nunc pro tunc December 1, 2019. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: ditif„,)xid42 g1 Weld County Clerk to the Board BY: Mike Freeman, Chair no, Pro -Tern Deputy Clerk to the Boar APPR• . AS TO FO Date of signature: 43/25/20 cc: HSD o4/o&/20 2020-0907 HR0092 ?�1t,+ ID 1:P 3 3 5 3 PRIVILEGED AND CONFIDENTIAL MEMORANDUM DATE: December 30, 2019 TO: Board of County Commissioners — Pass -Around FR: Judy A. Griego, Director, Human Services RE: Child Protection Agreement for Services with Polaris Partners Counseling and Consulting, Inc. Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Child Protection Agreement for Services with Polaris Partners Counseling and Consulting, Inc. The Department is requesting to enter into an agreement for various services with Polaris Partners Counseling and Consulting, Inc. The major provisions of this Agreement are as follows: Term Service(s) and Funding Rate(s) December 1, 2019- Intensive In -Home Behavioral May 31, 2020 Health Services $125.00/Hour (In -Home Therapy, English. Team meetings.) $160.00/Hour (In -Home Therapy, Spanish/Bilingual. Team meetings.) $75.00/Hour (Wraparound Facilitator. Team meetings.) Intensive In -Home Individual and Family Therapy $180.00/Hour (In -Home Therapy, English. Team meetings.) $240.00/Hour (In -Home Therapy, Spanish/Bilingual. Team meetings.) Substance Abuse Evaluation $350.00/Episode (Youth Substance Abuse Evaluation) $ .56/Mile (All services. Mileage outside of 30 -mile radius.) Core/Other Pass -Around Memorandum; December 30, 2019 — CMS 3353 Page 1 os/s 2020-0907 PRIVILEGED AND CONFIDENTIAL I do not recommend a Work Session. I recommend approval of this Agreement and authorize the Chair to sign. Sean P. Conway Mike Freeman, Pro -Tern Scott James Barbara Kirkmeyer, Chair Steve Moreno Approve Recommendation Work Session Schedule Other/Comments: Pass -Around Memorandum; December 30, 2019 - CMS 3353 Page 2 Karla Ford From: Sent: To: Cc: Subject: Approve Barbara Kirkmeyer Thursday, January 2, 2020 10:42 AM Karla Ford Sean Conway Re: Please Reply - PA FOR ROUTING: Polaris (CMS 3353) Sent from my iPhone On Jan 2, 2020, at 10:39 AM, Karla Ford <kford@weldgov.com> wrote: Please advise if you approve recommendation. Thank you! Karla Ford Office Manager, Board of Weld County Commissioners 1150 O Street, P.O. Box 758, Greeley, Colorado 80632 970.336-7204 :: kford at we!dgov.com :: www.weldgov,com :. My working hours are Monday -Thursday 7:00a.m.-4:00 p.m. Friday 7:00a.m. - Noon <image003.jpg> Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Tobi Cullins <cullinta@weldgov.com> Sent: Tuesday, December 31, 2019 3:23 PM To: Karla Ford <kford@weldgov.com> Cc: Barb Connolly <bconnolly@weldgov.com>; Bruce Barker <bbarker@weldgov.com>; Esther Gesick <egesick@weldgov.com>; HS Contract Management <HS-ContractManagement@co.weld.co.us>; Jamie Ulrich <ulrichjj@weldgov.com>; Judy Griego <griegoja@weldgov.com>; Lennie Bottorff <bottorll@weldgov.com> Subject: PA FOR ROUTING: Polaris (CMS 3353) Karla, Please see attached PA for routing related to a new agreement with Polaris Partners Counseling and Consulting. This item is in CMS (ID 3353). Thank you. Regards, Tobi A. Cullins Contract Management and Compliance Coordinator 1 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND POLARIS PARTNERS COUN WING AND CONSULTING, LLC This Agreement, made and entered into they of 20 tby and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department' and Polaris Counseling and Consulting, LLC, hereinafter referred to as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule. Exhibit B, C, and D are attached hereto and incorporated herein by this reference. Exhibit A is Weld County's Request for Proposal Number B1900025 which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH ESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Child Welfare Administration or other funding to the Department for Intensive In -Home Behavioral Health Services, Substance Abuse Evaluation Services, Life Coaching/Wraparound Facilitation, and Intensive In -Home Individual and Family Therapy. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on December 1, 2019 upon proper execution of this Agreement and shall expire May 31, 2020 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit 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 (hainleidPweideov.com 970-400-6210). No other Department staff or other party to the case may authorize services or modifications to services. c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation by the 7th of the month, following the month of service, utilizing billing forms required by the 1 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. Payment a. The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: i. The service being provided by the contractor is not a Medicaid eligible service; ii. The service is not deemed medically necessary; iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; iv. A Medicaid provider is not available to provide the needed service; v. Medicaid is exhausted for the needed service; or vi. Medicaid denied service. vii. The client is not eligible for Medicaid. b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule, attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent upon, the continuing availability of said funds for the purposes hereof. 2 d. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Financial Management At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMG Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule: a. If services are funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. b. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado Direct deposit enrollment form, which will be provided by the Department, with a voided check. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and - Title VII of the Civil Rights Act of 1964; and 3 - the Age Discrimination in Employment Act of 1967; and - the Equal Pay Act of 1963; and - the Education Amendments of 1972; and Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and - all regulations applicable to these laws prohibiting discrimination because of race, color, national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, Contractor and the Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any all Federal and/or State financial assistance. - Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, contractors and sub -contractors. b. Contractor is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the United States Department of Health and Human Services, Office for Civil Rights. c. Contractor assures that it will fully comply with all other applicable Federal and State laws which may govern the ability of the Department to comply with the relevant funding requirements. Contractor understands the source of funds to be accessed under the Agreement is determined by the Department. d. Contractor assures and certifies that it and its principals: - Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a Federal or State department or agency; and - have not, within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; and - are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state or local) with commission of any of the offenses enumerated in this certification; and - have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, or local) terminated for cause or default. e. Public Contracts for Services G.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this 4 contract. Contractor will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E -Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5- 102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to undertake pre -employment screening or job applicants while this Agreement is being performed. If Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contractor shall not terminate the contract if within three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. shall comply with reasonable requests made in the course of an investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and Employment. If Contractor participates in the State of Colorado program, Contractor shall, within twenty days after hiring a new employee to perform work under the contract, affirm that Contractor has examined the legal work status of such employee, retained file copies of the documents, and not altered or falsified the identification documents for such employees. Contractor shall deliver to the Department, a written notarized affirmation that it has examined the legal work status of such employee and shall comply with all of the other requirements of the State of Colorado program. If Contractor fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq., the Department, may terminate this Agreement for breach, and if so terminated, Contractor shall be liable for actual and consequential damages. f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if Contractor receives federal or state funds under the contract, Contractor must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the contract. If Contractor operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24- 76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. § 24-76.5- 103 prior to the effective date of the contract. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 3(d) of this Agreement. 5 9. Insurance Requirements Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, 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 during any warranty period. The required insurance shall be underwritten by an insurer licensed to do business in Colorado and rated by A.M. Best Company as "A"VIII or better. Each policy shall contain a valid provision or endorsement stating "Should any of the above -described policies by canceled or should any coverage be reduced before the expiration date thereof, the issuing company shall send written notice to the Weld County Director of General Services by certified mail, return receipt requested. Such written notice shall be sent thirty (30) days prior to such cancellation or reduction unless due to non-payment of premiums for which notice shall be sent ten (10) days prior. If any policy is in excess of a deductible or self -insured retention, the Department must be notified by the Contractor. Contractor shall be responsible for the payment of any deductible or self -insured retention. The Department reserves the right to require Contractor to provide a bond, at no cost to the Department, in the amount of the deductible or self -insured retention to guarantee payment of claims. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. Contractor shall maintain, at its own expense, any additional kinds or amounts of insurance that it may deem necessary to cover its obligations and liabilities under this Agreement. b. Types of Insurance: Contractor shall obtain, and maintain at all times during the term of any Agreement, insurance in the following kinds and amounts: i.Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance covering all of Contractor's employees acting within the course and scope of their employment. If Contractor is an Independent Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 0110/93 or equivalent, covering premises operations, fire damage, independent Contractors, 6 products and completed operations, blanket contractual liability, personal injury, and advertising liability with minimum limits as follows: - $1,000,000 each occurrence; - $2,000,000 general aggregate; - $50,000 any one fire; and - $500,000 errors and omissions. iii.Automobile Liability: Contractor shall maintain limits of $1,000,000 for bodily injury per person, $1,000,000 for bodily injury for each accident, and $1,000,000 for property damage applicable to all vehicles operating both on County property and elsewhere. iv.Additional Provisions: Policies for all general liability, excess/umbrella liability, liquor liability and pollution liability must provide the following: If any aggregate limit is reduced by twenty-five percent (25%) or more by paid or reserved claims, Contractor shall notify the Department within ten (10) days and reinstate the aggregates required; Unlimited defense costs in excess of policy limits; Contractual liability covering the indemnification provisions of this Agreement; A severability of interests provision; Waiver of exclusion for lawsuits by one insured against another; A provision that coverage is primary; and A provision that coverage is non-contributory with other coverage or self-insurance provided by the Department. v.For all general liability, excess/umbrella liability, liquor liability, pollution liability and professional liability policies, if the policy is a claims -made policy, the retroactive date must be on or before the contract date or the first date when any goods or services were provided to the Department, whichever is earlier. c. Contractors shall secure and deliver to County's Risk Administrator ("Administrator") at or before the time of execution of this Agreement, and shall keep in force at all times during the term of the Agreement as the same may be extended as herein provided, a commercial general liability insurance policy, including public liability and property damage, in form and company acceptable to and approved by said Administrator, covering all operations hereunder set forth in the related Bid or Request for Proposal. d. Proof of Insurance: Contractor shall provide a copy of this information to its insurance agent or broker and shall have its agent or broker provide proof of Contractor's required insurance. The Department reserves the right to require Contractor to provide a certificate of insurance, a policy, or other proof of insurance as required by the County's Risk Administrator in his sole discretion. e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal liability, liquor liability, and inland marine, Contractor's insurer shall name County as an additional insured. 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 7 requirements herein and shall procure and maintain the same coverages required of Contractor. Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers or other entities as insureds under its policies or shall ensure that all subcontractors maintain the required coverages. Contractor agrees to provide proof of insurance for all such subcontractors, independent contractors, sub -vendors, suppliers or other entities upon request by the Department. A provider of Professional Services (as defined in the Bid or RFP) shall provide the following coverage: Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and $2,000,000 aggregate limit for all claims. 10. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 12. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at 970-336-7235, and advise that the subpoena must be personally served. 13. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not 8 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 Damond Dotson, Co -Owner 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich, Director P.O. Box A Greeley, CO 80632 (970) 400-6510 18. Litigation For Contractor: Damond Dotson, Co -Owner P.O. Box 273061 Fort Collins, CO 80527 (866) 285-2929 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 9 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 not enter into any third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict 10 of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage. Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. Contractor shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality requirements. Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those 11 of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an 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. 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 12 and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. §§24-18-201 et seq. and §24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 34. Choice of Law/Jurisdiction Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 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 13 All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of the Department. In addition, all reports, documents, data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the Department. Contractor shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of the Department. 38. Interruptions Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. 39. Severability If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY; ATTEST: _ v' �`�';� BOARD OF COUNTY COMMISSIONERS Weld 'oun Cl: ktothe Boar ��/r WELD COUNTY, COLORADO By Deputy Clerk to th 14 Mike Freeman, Chair MAR 18 2020 CONTRACTOR: Polaris Partners Counseling and Consulting, LLC P.O. Box 273061 Fort Collins, CO 80527 (866) 285-2929 By: Date: ✓oom(,G'tra# Damond Dotson (Mar 4, 2020) Damond Dotson, Ph.D., LMFT — Co -Owner Mar 4, 2020 020 -190 7 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 POLARIS PARTNERS COUNSELING & CONSULTING Entity Ownership Please let this document show that Polaris Partners Counseling and Consulting, LLC is a partnership consisting of the following owners: Damond Dotson, PhD, LMFT Thadeus Jessen, MA, LPC Victoria Gerber, MA, LPC, CACII Practice office is located at: 409 Mason Ct. #121, Fort Collins, CO 80524 With a Mailing Address of: PO Box 273061 Fort Collins, CO 80527 Please show that this bid for services for Weld County Child Welfare, BID Number B1900025, is agreed to by all partners and is signed by Victoria Gerber on behalf of the partnership. kze Victoria Gerber, LPC, CACII Therapist/Co-Owner Polaris Partners Counseling and Consulting, LLC PO Box 273061, Fort Collins CO 80527 1-28-2019 Date 866-285-2929 info@polarispartnerscc.com EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide the following services under this Agreement, as referred by the Department. a. Intensive In -Home Behavioral Health Services: Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, Contractor will address individual and familial patterns of addiction, mental health issues and community involvement. All treatment will be individualized and tailored to the specific needs and strengths of the client and/or family. Evidence -based practices will be used to help client and family develop skills and ability to manage emotions, develop healthy interpersonal skills, and strengthen family and social bonds in addition to other specific treatment goals. i. Capacity to Provide Services: One (1) to 10 hours per week, dependent upon Contractor's current caseloads. ii. Goals of Service: To help client and/or family achieve identified individualized treatment goals toward improved function, emotional stability, and ability to behave appropriately in their communities. iii. Outcomes of Service: Treatment outcomes will depend on many variables, primarily hinging on the ability and willingness of clients to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Contractor will: 1. Strive to meet clients where they are. 2. Consistently provider premium quality individualized behavioral health services. iv. Target Population: 1. Youth, ages five (5) to 18 2. All genders 3. Specializing in at -risk populations v. Service Access: 1. Contractor will travel within Weld County for an additional fee. 2. Office: 409 Mason Court, #121, Fort Collins, CO 80524. 3. Contractor has capacity for video-conferencing. vi. Language: English and Spanish. Contractor has one bilingual in -home therapist with limited availability. b. Substance Abuse Evaluation Services: Utilizing evidence -based assessments and therapeutic interventions, Contractor will complete an evaluation that addresses individual and familial patterns of addiction, mental health issues and community involvement. i. Capacity for Services: Stand-alone service completed within 14-21 days of receiving referral. ii. Goals of Service: A comprehensive evaluation to assess for substance abuse symptoms, history and risk factors/severity, as well as to provider treatment recommendations, completed by a Licensed Professional Counseling (LPC) and Certified Addictions Counseling II (CACII). Evaluation will include a thorough assessment of mental health symptoms, history and risk factors/severity, including: social family history, school/employment history, legal involvement, and trauma/abuse history. Contractor will interview client and other relevant entities to gather all necessary information and will compile results of interview and test battery in a narrative report. The report will include pertinent regarding bio-psycho-social factors of substance misuse/addiction and 1 will conclude with recommendations for types of treatment and level of care appropriate. iii. Outcomes of Service: Comprehensive background information and professional recommendations as to the appropriateness and necessity of substance abuse services and the level of care most fitting to client's needs. iv. Target Populations: Ages 10 to 21 years old, all genders, dealing with substance use issues as well as co-occurring mental health issues. v. Service Access: 1. Contractor will travel within Weld County for an additional fee. 2. Office: 409 Mason Court, #121, Fort Collins, CO 80524. 3. Contractor has capacity for video-conferencing. vi. Language: English only. c. Intensive In -Home Individual and Family Therapy: Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, Contractor will address individual and familial patterns of addiction, mental health issues and community involvement. All treatment will be individualized and tailored to the specific needs and strengths of the client and/or family. Evidence -based practices will be used to help client and family develop skills and ability to manage emotions, develop healthy interpersonal skills, and strengthen family and social bonds in addition to other specific treatment goals. i. Capacity to Provide Services: One (1) to 10 hours per week, dependent upon Contractor's current caseloads. ii. Goals of Service: To help client and/or family achieve identified individualized treatment goals toward improved function, emotional stability, and ability to behave appropriately in their communities. iii. Outcomes of Service: Treatment outcomes will depend on many variables, primarily hinging on the ability and willingness of clients to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Contractor will: 1. Strive to meet clients where they are. 2. Consistently provider premium quality individualized behavioral health services. iv. Target Population: 1. Youth, ages five (5) to 18 years of age 2. All genders 3. Specializing in at -risk populations v. Service Access: 1. Contractor will travel within Weld County for an additional fee. 2. Office: 409 Mason Court, #121, Fort Collins, CO 80524. 3. Contractor has capacity for video-conferencing. vi. Language: English and Spanish. Contractor has one bilingual in -home therapist with limited availability. 2. Contractor will respond to the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 3. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral 2 period, the Contractor will notify the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). 4. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. After three (3) "no-shows, " Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). 5. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com) immediately via email, to discuss service continuation. 6. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 7. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 8. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 9. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 10. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as the meeting is at least one hour in length, the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 3 11. 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. 4 Polaris Partners Counseling and Consulting, LLC Proposal to Provide Substance Abuse Evaluation Weld County, CO 1. Bidder's legal entity name: 2. Program name or service type being proposed: Polaris Partners Counseling and Consulting, LLC Substance Abuse Evaluation 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Utilizing evidence -based assessments and therapeutic interventions, therapist completing evaluation will address individual and familial patterns of addiction, mental health issues and community involvement. The following specific tools and interventions will be utilized: o PHQ-9 (Depressive symptoms and severity) o GAD -7 (Anxiety symptoms and severity) o ACE (Childhood trauma and severity) o General clinical interview including information regarding: • Presenting Problem/reason for meeting • Social and family history, major life events • Family mental health/substance abuse history • School/work status and history • Medical information • Hobbies and interests • Strengths and challenges • Spiritual/Religious, and Cultural background/practices/traditions/customs • Appetite, sleep, energy, and libido • Legal and social services status and history ■ Abuse/trauma history • Substance use history ■ Safety assessment (suicide, self -harm, homicide risk) Other mental health symptoms (depression, anxiety, mood, conduct, attention, psychosis, personality) 4. Capacity to Provide Services (ex. 4 hours/week). Substance Abuse Evaluation is a stand-alone service and will be completed within 14 to 21 days of receiving referral. Goals of the service. A comprehensive evaluation to assess for substance abuse symptoms, history, and risk factors/severity, as well as to provide treatment recommendations. This evaluation will also include a thorough assessment of mental health symptoms, history, and risk factors/severity, including: Bid No.: B1900025 Polaris Partners Counseling and Consulting, LLC Proposal to Provide Substance Abuse Evaluation Weld County, CO social/family history, school/employment history, legal involvement, and trauma/abuse history. Therapist will interview client and other relevant entities to gather all necessary information and will compile results of interview and test battery in a narrative report. This report will include pertinent information regarding bio-psycho-social factors of substance misuse/addiction and will conclude with recommendations for types of treatment and level of care appropriate given client's individual symptoms, risk severity, and life circumstances. Therapist completing this report is a Licensed Professional Counselor (LPC) and Certified Addictions Counselor II (CACII) in the State of Colorado. 5. Outcomes of service. The outcome of this interview and assessment of client's need for substance abuse services will be that the appropriate entities providing professional support to client and/or family are given comprehensive background information and professional recommendations by evaluating therapist as to the appropriateness and necessity of substance abuse services and the level of care most fitting to client's need. 6. Target population for service. Clients between the ages of 10 and 21, any gender, dealing with substance use issues as well as co- occurring mental health issues will be served. Client and family as well as family supports may be interviewed. 7. Service access. Polaris Partners therapists can travel to Weld County homes to provide evaluation services. Office is also available for therapy sessions should client(s) choose to travel or services. Office location is currently: 409 Mason Ct. #121, Fort Collins, CO 80524. (Office may move to a new location within the year, new address will be provided) Therapists do have the capacity to provide video-conferencing via EMR platform telehealth software. 8. Languages service is available in. English 9. Rates of service. Youth Substance Abuse Evaluation: Rate: $350 flat rate See above description of service for more information. Bid No.: B1900025 Polaris Partners Counseling and Consulting, LLC Proposal to Provide Intensive In -Home Behavioral Health Services Weld County, CO providers, treatment plan updates, and court updates. Polaris Partners therapists provide services in English unless Spanish-speaking therapist is requested. Bilingual service, if available at the time of referral, will be provided at a higher rate (see below). Wraparound Facilitator: Life coaches hold a bachelor's degree in human services fields and provide a variety of services: involvement in prosocial activities, job seeking support, behavioral coaching on skills learned in therapy, identification of community resources, life skill/independent living skill development, coping skill development. Other services provided include crisis response availability to youth, family, and teams, case management activities, coordination and planning with other involved professionals and service providers, treatment plan updates, and court updates. Youth Substance Abuse Evaluation: A comprehensive evaluation to assess for substance abuse symptoms, history, and risk factors/severity, as well as to provide treatment recommendations. This evaluation will also include a thorough assessment of mental health symptoms, history, and risk factors/severity, including: social/family history, school/employment history, legal involvement, and trauma/abuse history. Therapist will interview client and other relevant entities to gather all necessary information and will compile results of interview and test battery in a narrative report. This report will include pertinent information regarding bio-psycho-social factors of substance misuse/addiction and will conclude with recommendations for types of treatment and level of care appropriate given client's individual symptoms, risk severity, and life circumstances. Therapist completing this report is a Licensed Professional Counselor (LPC) and Certified Addictions Counselor II (CACII) in the State of Colorado. Mileage reimbursement Mileage will be billed for all locations further than a 20 -mile radius from 409 Mason Ct. Fort Collins, CO 80524. 5. Outcomes of service. Treatment outcomes depend on many variables, primarily hinging on the ability and willingness of clients to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Although outcomes cannot be absolutely guaranteed, Polaris Partners has always and will continue to strive to meet clients where they are and consistently provide premium quality individualized behavioral health services with the goal being to help client and/or family achieve identified treatment goals toward improved function, emotional stability, and ability to behave appropriately within their communities. 6. Target population for service. Polaris Partners serves youth ages 5 to 18 (sometimes younger depending on circumstance), all genders, specializing in at -risk populations. Clients dealing with mental health and substance use issues will be served. Polaris Partners providers also work with families to help create a healthy and functional family system and environment in which the client may thrive. Bid No.: B1900025 Polaris Partners Counseling and Consulting, LLC Proposal to Provide Intensive In -Home Behavioral Health Services Weld County, CO 7. Service access. Polaris Partners therapists can travel to Weld County homes to provide in -home family and individual therapy sessions. Please see Mileage Reimbursement bid below for mileage rates. Office is also available for therapy sessions should client(s) choose to travel or services. Office location is currently: 409 Mason Ct. #121, Fort Collins, CO 80524. (Office may move to a new location within the year, new address will be provided) Therapists do have the capacity to provide video-conferencing via EMR platform telehealth software. 8. Languages service is available in. English and Spanish (Polaris Partners has one bilingual in -home therapist on staff, availability is limited) 9. Rates of service. In -Home Therapy (English): Rate: $125 per hour (All in person contact will be billed this rate including therapy, team meetings, and court appearances.) See above description of service for more information. In -Home Therapy (Spanish/Bilingual): Rate: $160 per hour (All in person contact will be billed this rate including therapy, team meetings, and court appearances.) See above description of service for more information. Wraparound Facilitator Rate: $75 per hour See above description of service for more information. Mileage reimbursement: Rate: $60 per hour See above description of service for more information. Youth Substance Abuse Evaluation: Rate: $350 flat rate See above description of service for more information. Bid No.: B1900025 Polaris Partners Counseling and Consulting, LLC Proposal to Provide Intensive In -Home Behavioral Health Services Weld County, CO 1. Bidder's legal entity name: 2. Program name or service type being proposed: 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Home -Based Intervention, Mental Health Services, Mediation/Intensive Family Services Polaris Partners Counseling and Consulting, LLC Intensive In -Home Individual and Family Therapy Utilizing evidence -based Wraparound principles and Cognitive Behavioral Therapy techniques, therapists will address individual and familial patterns of addiction, mental health issues and community involvement. All treatment will be individualized and tailored to the specific needs and strengths of the client and/or family. Evidence -based practices will be used to help client and family develop skills and ability to manage emotions, develop healthy interpersonal skills, and strengthen family and social bonds in addition to other specified treatment goals. 4. Capacity to Provide Services (ex. 4 hours/week). Depending on various therapists' caseloads at the time of referral request, Polaris therapists will be available to provide anywhere from 1 to 10 hours of intensive in -home therapy per week. Goals of the service. To help client and/or family achieve identified individualized treatment goals toward improved function, emotional stability, and ability to behave appropriately within their communities. Polaris Partners providers will collaborate with client's team to ensure client has access to necessary resources for the highest chance of achieving success. Therapists will provide weekly individual and family therapy as requested by the team and family. All in person contact will be billed the same rate including therapy, team meetings, and court appearances. Other services provided include crisis response availability to youth, family, and teams, case management activities, coordination and planning with other involved professionals and service providers, treatment plan updates, and court updates. Polaris Partners therapists provide services in English unless Spanish-speaking therapist is requested. Bilingual service, if available at the time of referral, will be provided at a higher rate (see below). 5. Outcomes of service. Bid No.: 81900025 Polaris Partners Counseling and Consulting, LLC Proposal to Provide Intensive In -Home Behavioral Health Services Weld County, CO Treatment outcomes depend on many variables, primarily hinging on the ability and willingness of clients to participate fully in learning new skills and processing through barriers to success in learning to maintain stability and function, as well as the strength of the therapeutic relationship. Although outcomes cannot be absolutely guaranteed, Polaris Partners has always and will continue to strive to meet clients where they are and consistently provide premium quality individualized behavioral health services with the goal being to help client and/or family achieve identified treatment goals toward improved function, emotional stability, and ability to behave appropriately within their communities. 6. Target population for service. Polaris Partners serves youth ages 5 to 18 (sometimes younger depending on circumstance), all genders, specializing in at -risk populations. Clients dealing with mental health and substance use issues will be served. Polaris Partners providers also work with families to help create a healthy and functional family system and environment in which the client may thrive. 7. Service access. Polaris Partners therapists can travel to Weld County homes to provide in -home family and individual therapy sessions. Office is also available for therapy sessions should client(s) choose to travel or services. Office location is currently: 300 E. Horsetooth Rd., Suite 200, Fort Collins, CO 80525 Therapists do have the capacity to provide video-conferencing via EMR platform telehealth software. 8. Languages service is available in. English and Spanish (Polaris Partners has one bilingual in -home therapist on staff, availability is limited) 9. Rates of service. In -Home Therapy (English): Rate: $180 per hour (All in person contact will be billed this rate including therapy, team meetings, and court appearances.) See above description of service for more information. In -Home Therapy (Spanish/Bilingual): Rate: $240 per hour (All in person contact will be billed this rate including therapy, team meetings, and court appearances.) See above description of service for more information. 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: Home -Based Intervention - Intensive In -Home Individual and Family Therapy BIDDER LEGAL ENTITY NAME: Polaris Partners Counseling and Consulting, LLC APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION 111WVISOR INFO No. Last Name First Name Work# Work Email Education Level Degree Focus Licensure/ Credentials DORA # (If applicable) Last Name First Name r Work # 1 Dotson Damond 866-285-2929 damond.dotson@polarispartnerscc.com PhD Marriage and Family Counseling LMFT MFT.0000576 Jessen Thadeus 866-285-2929 2 Jessen Thadeus 866-285-2929 thadeus.jessen@polarispartnerscc.com MA Clinical Mental Health Counseling LPC LPC.0003535 Dotson Damond 866-285-2929 3 Gerber Victoria 866-285-2929 victoria.gerber@polarispartnerscc.com MA Clinical Mental Health Counseling LPC, CACII LPC.0014107, ACB.0008377 Dotson Damond 866-285-2929 4 Wilson Eric 866-285-2929 eric.wilson@polarispartnerscc.com ME Counseling and Career Development LPCC LPCC.0015367 Dotson Damond 866-285-2929 5 Lucas Rachel 866-285-2929 rachel.lucas@polarispartnerscc.com MA Clinical Mental Health Counseling LPC CACII LPC.0013958, ACB.0008341 Dotson Damond 866-285-2929 6 Andresen Glenda 866-285-2929 glenda.andresen@polarispartnerscc.com MA Marriage and Family Counseling LMFT MFT.0000632 Dotson Damond 866-285-2929 7 Ryan Emilie 866-285-2929 amilie.ryan@polarispartnerscc.com MA Clinical Mental Health Counseling LPC LPC.0013811 Dotson Damond 866-285-2929 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: Home -Based Intervention - Intensive In -Home Individual and Family Therapy BIDDER LEGAL ENTITY NAME: Polaris Partners Counseling and Consulting, LLC APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION No. Last Name First Name ` Work# Work Email Education Level Degree Focus Licensure/ Credentials DORA # ;' (If applicable) 1 Dotson Damond 866-285-2929 damond.dotson@polarispartnerscc.com PhD Marriage and Family Counseling LMFT MFT.0000576 2 Jessen Thadeus 866-285-2929 thadeus.jessen@polarispartnerscc.com MA Clinical Mental Health Counseling LPC LPC.0003535 3 Gerber Victoria 866-285-2929 victoria.aerber@polarispartnerscc.com MA Clinical Mental Health Counseling LPC, CACII LPC.0014107, ACB.0008377 4 Wilson Eric 866-285-2929 eric.wilson@polarispartnerscc.com ME Counseling and Career Development LPCC LPCC.0015367 5 Lucas Rachel 866-285-2929 rachel.lucas@polarispartnerscc.com MA Clinical Mental Health Counseling LPC CACII LPC.0013958, ACB.0008341 6 Andresen Glenda 866-285-2929 glenda.andresen@polarispartnerscc.com MA Marriage and Family Counseling LMFT MFT.0000632 7 Ryan Emilie 866-285-2929 amilie.rvan@polarispartnerscc.com MA Clinical Mental Health Counseling LPC LPC.0013811 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Bid No.: B1900025 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 Intensive In -Home Behavioral Health Services: $125.00/Hour (In -Home Therapy, English) $160.00/Hour (In -Home Therapy, Spanish/Bilingual) $75.00/Hour (Wraparound Facilitator) Intensive In -Home Individual and Family Therapy: $180.00/Hour (In -Home Therapy, English) $240.00/Hour (In -Home Therapy, Spanish/Bilingual) Substance Abuse Evaluation: $350.00/Episode (Youth Substance Abuse Evaluation) Mileage: $ .56/Mile (Mileage outside of 30 -mile radius from 409 Mason Court, #121, Fort Collins, CO 80524.) Contractor will be above rates for the identified service, associated team meetings and court appearances. 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. PROVIDER INFORMATION FORM Weld County Department of Human Services Polaris Partners Counseling and Consulting, LLC AGENCY OR PRIVATE PRACTICE Damond Dotson, PhD, LMFT Co-Owner/Therapist PRIMARY CONTACT— FULL NAME (866)285-2929 PHONE NUMBER damond.dotson@polarispartnerscc.com PRIMARY CONTACT— E-MAIL ADDRESS PO Box 273061 AGENCY MAILING ADDRESS TRAILS PROVIDER ID (If Known) PRIMARY CONTACT - TITLE (2081567-5844 EXT. FAX NUMBER www.polarispartnerscc.com AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) Fort Collins, CO CITY 80527 ZIP REFERRAL CONTACT Damond Dotson REFFERAL CONTACT— FULL NAME (8661285-2929 REFERRAL CONTACT — PHONE NUMBER EXT. Co-Owner/Therapist REFERRAL CONTACT - TITLE damond.dotson@polarispartnerscc.com REFERRAL CONTACT — E-MAIL ADDRESS BILLING CONTACT Damond Dotson BILLING CONTACT— FULL NAME (866 ) 285-2929 BILLING CONTACT— PHONE NUMBER EXT. Co-Owner/Therapist BILLING CONTACT - TITLE damond.dotson@polarispartnerscc.com 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: (Victoria Gerber— Co-Owner/Therapist— Polaris Partners Counseling and Consulting, LLC) Date of Signature: 01/27/19 Bid No.: B1900025 POLARIS PARTNERS COUNSELING & CONSULTING January 28, 2019 Polaris Partners Counseling and Consulting, LLC 409 Mason Ct. #121, Fort Collins, CO 80524 PO Box 273061, Fort Collins, CO 80527 866-285-2929 To Whom It May Concern, This letter is to confirm that we, Polaris Partners Counseling and Consulting, LLC, are submitting a bid proposal for Weld County Child Welfare (Bid No.: B1900025) for the year 2019-2020. We intend to provide the following services with individual service bid proposals attached for each: - Intensive In -Home Therapy — Individual and Family o English and Spanish/bilingual available Substance Abuse Evaluation and Therapy - Life Coaching - Mileage Reimbursement Our providers listed in the accompanying Staff Data Sheets are qualified to provide in - home services to residents of Weld County and we guarantee the "ability to deliver the services as proposed and will comply with the specific requirements set forth by Weld County". We also guarantee the "capacity to be organized, responsive and to quickly and successfully schedule services as requested."* * These terms are quoted from the Weld County Instructions to Bidders for Child Welfare Bid No.: B1900025 for 2019-2020. Please see attached supporting documents requesting the ability to provide mental health and substance abuse services to residents of Weld County. Sincerely, Victoria Gerber, LPC, CACII Partner/Therapist Polaris Partners Counseling and Consulting, LLC victoria.gerber@polarispartnerscc.com PO Box 273061, Fort Collins CO 80527 866-285-2929 info@polarispartnerscc.com MWILLIAMS POLAPAR-01 ACORO° CERTIFICATE OF LIABILITY INSURANCE �� DATE(MM/ 12/11/2019 Y) 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 Howard Insurance Agency, Inc. 6900 Wisconsin Ave Fifth Floor Chevy Chase, MD 20815 CONTACT NAME: PHONE FAX (A/C, No, Ext): (301) 652-2500 (A/c, No):(301) 652-2530 noDRlEss: INFO@HOWARD-INSURANCE.COM INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Hartford Insurance Group 29424 INSURED Polaris Partners Counseling & Counseling LLC PO Box 273061 Fort Collins, CO 80527 INSURER B:Beazley Insurance Company Inc. 37540 INSURER C: INSURER D : - INSURER E : INSURER F : OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF IMM/DDIYYYYI POLICY EXP IMMIDD/YYYYI LIMITS A COMMERCIAL GENERAL LIABILITY 42SBAUH0128 12/5/2019 12/5/2020 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) 1,000,000 $ MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE POLICY OTHER: LIMIT APPLIES TOO PER: LOC GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 $ A AUTOMOBILE X LIABIUTY ANY AUTO OWNED AUTOS OONLY AUTOS ONLY X SCHEDULED AUTOS WN ARTOS ONLY 42SBAUH0128 12/5/2019 12/5/2020 COMBINED SINGLE LIMIT (Ea accident) 2,000,000 $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (Peer PROPERTYtDAMAGE $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below YIN N / A 42WECCR9690 12/5/2019 12/5/2020 X PERTUTE OTH- STAER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ B A Data Breach/Cyber Bus. Personal Prop. V1756D190601 42SBAUH0128 12/5/2019 12/5/2019 12/5/2020 12/5/2020 Limit REPLACEMENT COST 1,000,000 25,100 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is listed as an additional Insured with respect to General Liability and Commercial Auto Liability where required by written contract. CERTIFICATE HOLDER CANCELLATION County of Weld 1150 'O' Street Greeley, CO 80631 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Contract Form Entity Information Entity Name* POLARIS PARTNERS LLC New Contract Request Entity ID* @00036707 Contract Name* POLARIS PARTNERS COUNSELING AND CONSULTING, LLC (CHILD PROTECTION AGREEMENT FOR SERVICES) Contract Status CTB REVIEW ❑ New Entity? Contract ID 3353 Contract Lead* CULLINTA Contract Lead Email cullinta@co.weld.co.us Contract Description* NEW AGREEMENT FOR SERVICES FUNDING: COREJOTHER. TERM Contract Description 2 Contract Type* AGREEMENT Amount* $0.00 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServices@weldgov.com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WELD GOV.COM Parent Contract ID Requires Board Approval YES Department Project # DECEMBER 1, 2019 -MAY 31 2020. Requested BOCC Agenda Date* 01/08/2020 Due Date 01104/2020 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be induded? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On Base Contract Dates Effective Date Review Date* 04/01/2020 Termination Notice Period Committed Delivery Date Renewal Date Expiration Date 05/3112020 Contact Information Contact Info Contact Name Purchasing Purchasing Approver Approval Process Department Head JAMIE ULRICH DH Approved Date 03/09/2020 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 03/18/2020 Originator CULLINTA Contact Type Contact Email Finance Approver BARB CONNOLLY Contact Phone 1 Contact Phone 2 Purchasing Approved Date Finance Approved Date 03111;2020 Tyler Ref # AG 031820 Legal Counsel GABE KALOUSEK Legal Counsel Approved Date 03/11/2020 Submit Hello