HomeMy WebLinkAbout20192263.tiff, CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND HEART -CENTERED COUNSELING
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This Agreement, made and entered into the/Jday of 019, by and between the Board of Weld
County Commissioners, on behalf of the Weld County Departme of Human Services, hereinafter referred to as
the "Department' and Heart -Centered Counseling, hereinafter referred to as the "Contractor".
The parties to this Agreement understand and agree that the provisions of this Agreement specifically
include the following documents: Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response
to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule. Exhibit B, C, and D are attached
hereto and incorporated herein by this reference. Exhibit A is Weld County's Request for Proposal Number
B1900025, which is incorporated into this agreement by reference and will be provided upon request to the
Department.
W ITN 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 Core Services or other funding to
the Department for Medication Management and Mental Health Services.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows:
1. Term
This agreement shall become effective on June 1, 2019, upon proper execution of this Agreement and
shall expire May 31, 2020, unless sooner terminated as provided herein. The agreement is for a period of
three years. However, the agreement must be renewed by both parties, in writing, on an annual basis.
2. Scope of Services
Services shall be provided by the Contractor to any person(s) eligible for services in compliance with
Exhibit B, Contractor's Response to Request for Proposal and Exhibit C, Scope of Services.
3. Referrals, Billing and Tracking
a. Contractor understands and will comply with all aspects of the referral authorization, billing and
tracking requirements as set forth by the Department. Failure to comply with all aspects may result
in a forfeiture of payment.
b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e-
mail address prior to the start of this Agreement. Contractor acknowledges that services are not
authorized until the Contractor has received an authorized referral form from the Department.
Contractor further acknowledges that services provided prior to the authorized start date or outside
the scope of services on the referral form will not be eligible for reimbursement.
Contractor acknowledges that any and all modifications to an existing referral must be approved
through the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). No other
Department staff or other party to the case may authorize services or modifications to services.
c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation
by the 7th of the month, following the month of service, utilizing billing forms required by the
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Department. Contractor agrees to utilize the Client Verification Form for all scheduled and
unscheduled face-to-face services with the exception of home studies and monitored sobriety
testing. Contractor agrees that original complete Client Verification Forms are to be submitted with
the Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received
after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure
to meet 60 -day deadline may result in termination of the Agreement.
d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service,
for each client receiving ongoing services. Monthly reports will be submitted through the
Department's online reporting system, unless otherwise directed or agreed to by the Department.
Monthly reports for ongoing services must include the following information, entered in the
"Narrative" box for each date of service:
a. Date and time of service
b. Where the service took place
c. Clinician/therapist name
d. Clients participating
e. What interventions were used, recommendations and/or goals discussed
f. Any and all safety concerns
One-time services will be verified through receipt of the completed product (ex. psychological
evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will
be the test result. A completed home study may be a full, partial or denied study, as determined by
the Department.
Contractor will document in detail any and all observed or verbalized concerns regarding any child
whom the Contractor is working with under the Agreement. Areas of concern may include, but are
not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be
reported immediately to the caseworker AND on the required monthly report.
4. Payment
a. The Department and the Contractor agree that all benefits from private insurance and/or other
funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's
Compensation must be exhausted before Core Services or other Department funds can be accessed
for services. Exceptions to this Paragraph may include, if approved by the Department, the following:
i. The service being provided by the contractor is not a Medicaid eligible service;
ii. The service is not deemed medically necessary;
iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider
or service be used;
iv. A Medicaid provider is not available to provide the needed service;
v. Medicaid is exhausted for the needed service; or
vi. Medicaid denied service.
vii. The client is not eligible for Medicaid.
b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit
B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate
Schedule, attached hereto and incorporated herein by reference, so long as services are rendered
satisfactorily and in accordance with the Agreement.
c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent
upon, the continuing availability of said funds for the purposes hereof.
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d. The Department may withhold reimbursement if Contractor has failed to comply with any part of
the Agreement, including the Financial Management requirements, program objectives, contractual
terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may
appeal such circumstance in writing to the Director of Human Services. The decision of the Director
of Human Services shall be final.
5. Financial Management
At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall
comply with the administrative requirements, cost principles and other requirements set forth in the
Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds
expended under this Agreement must conform to the Single Audit Act of 1984 and OMG Circular A-133.
6. Payment Method
Unless otherwise provided in Exhibit B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D,
Rate Schedule:
a. If services are funded through Core Services, Contractor agrees to accept reimbursement
through ACH direct deposit one time per month.
b. If Contractor is not currently set up with the State of Colorado to accept direct deposit,
Contractor agrees to complete and submit an, which will be provided by the Department, with a
voided check. Failure to complete and submit this form and voided check in a timely and accurate
manner may result in a delay of payment.
c. Contractor agrees to accept payment through county warrant when funding source does not
allow for direct deposit.
7. Compliance with Applicable Laws
a. At all times during the performance of this Agreement, Contractor will strictly adhere to all
applicable Federal and State laws, order, and applicable standards, regulations, interpretations
and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all
applicant/recipient records, papers, documents, tapes and any other materials that have been or may
hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws
and regulations, including, but not limited to the following:
- Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil
Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45
C.F.R. Part 80 et. seq.; and
- all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of
race, creed, color, sex, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination under the approved Agreement.
- Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its
implementing regulations, 45 C.F.R. Part 84; and
- the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its
implementation regulations, 45 C.F.R. Part 91; and
- Title VII of the Civil Rights Act of 1964; and
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- the Age Discrimination in Employment Act of 1967; and
- the Equal Pay Act of 1963; and
- the Education Amendments of 1972; and
- Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and
- all regulations applicable to these laws prohibiting discrimination because of race, color,
national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of
1973, as amended, cited above. If necessary, Contractor and the Department will resist in
judicial proceedings any efforts to obtain access to client records except as permitted by 42
C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken
to assure that small and minority businesses are utilized, when possible, as sources of
supplies, equipment, construction and services. This assurance is given in consideration of
and for the purpose of obtaining any all Federal and/or State financial assistance.
- Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks
for all employees, contractors and sub -contractors.
b. Contractor is further charged with the knowledge that any person who feels that s/he has been
discriminated against has the right to file a complaint either with the Colorado Department of Human
Services or with the United States Department of Health and Human Services, Office for Civil Rights.
c. Contractor assures that it will fully comply with all other applicable Federal and State laws which
may govern the ability of the Department to comply with the relevant funding requirements.
Contractor understands the source of funds to be accessed under the Agreement is determined by
the Department.
d. Contractor assures and certifies that it and its principals:
- Are not presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from covered transaction by a Federal or State department or agency;
and
- have not, within a three-year period preceding this Agreement, been convicted of or
had a civil judgment rendered against them for commission of fraud or criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State or
Local) transaction or contract under public transaction; violation of federal or state antitrust
statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction
of records, making false statements, or receiving stolen property; and
- are not presently indicted for or otherwise criminally or civilly charged by a government
entity (federal, state or local) with commission of any of the offenses enumerated in this
certification; and
- have not, within a three-year period preceding this Agreement, had one or more public
transactions (federal, state, or local) terminated for cause or default.
e. Public Contracts for Services C.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that it
does not knowingly employ or contract with an illegal alien who will perform work under this
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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.
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9. Insurance Requirements
Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld
County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent
acts or omissions of the Contractor, its subcontractor, or their employees, volunteers, or agents while
performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless
Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents.
Contractor shall provide the liability insurances (including professional liability insurances where
necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged
in the performance of this Agreement which are required under Weld County's Request for Proposal, and
required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the
acceptable evidence that such coverage is in effect within seven (7) days of the date of this Agreement.
At a minimum, Contractor shall procure, either personally or through its employer as applicable to the
Contractor's business, at its own expense, and maintain for the duration of the work, the following
insurance coverage. Weld County, State of Colorado, by and through the Board of County Commissioners
of Weld County, its employees and agents, shall be named as additional named insured on the insurance,
where permissible the insurance provider.
a. General Requirements: Contractors must secure, at or before the time of execution of
any agreement or commencement of any work, the following insurance covering all operations,
goods or services provided pursuant to this request. Contractors shall keep the required insurance
coverage in force at all times during the term of the Agreement, or any extension thereof, and
during any warranty period. The required insurance shall be underwritten by an insurer licensed
to do business in Colorado and rated by A.M. Best Company as "A"VIII or better. Each policy shall
contain a valid provision or endorsement stating "Should any of the above -described policies by
canceled or should any coverage be reduced before the expiration date thereof, the issuing
company shall send written notice to the Weld County Director of General Services by certified
mail, return receipt requested. Such written notice shall be sent thirty (30) days prior to such
cancellation or reduction unless due to non-payment of premiums for which notice shall be sent
ten (10) days prior. If any policy is in excess of a deductible or self -insured retention, the
Department must be notified by the Contractor. Contractor shall be responsible for the payment
of any deductible or self -insured retention. The Department reserves the right to require
Contractor to provide a bond, at no cost to the Department, in the amount of the deductible or
self -insured retention to guarantee payment of claims. The insurance coverages specified in this
Agreement are the minimum requirements, and these requirements do not decrease or limit the
liability of Contractor. Contractor shall maintain, at its own expense, any additional kinds or
amounts of insurance that it may deem necessary to cover its obligations and liabilities under this
Agreement.
b. Types of Insurance: Contractor shall obtain, and maintain at all times during the term of
any Agreement, insurance in the following kinds and amounts:
i.Workers' Compensation Insurance as required by state statute, and Employer's Liability
Insurance covering all of Contractor's employees acting within the course and scope of
their employment. If Contractor is an Independent Contractor, as defined by the
Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must
submit to the Department a Declaration of Independent Contractor Status Form prior to
the start of this agreement.
ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 0110/93
or equivalent, covering premises operations, fire damage, independent Contractors,
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products and completed operations, blanket contractual liability, personal injury, and
advertising liability with minimum limits as follows:
$1,000,000 each occurrence;
- $2,000,000 general aggregate;
- $50,000 any one fire; and
- $500,000 errors and omissions.
iii.Automobile Liability: Contractor shall maintain limits of $1,000,000 for bodily injury per
person, $1,000,000 for bodily injury for each accident, and $1,000,000 for property
damage applicable to all vehicles operating both on County property and elsewhere.
iv.Additional Provisions: Policies for all general liability, excess/umbrella liability, liquor
liability and pollution liability must provide the following:
- If any aggregate limit is reduced by twenty-five percent (25%) or more
by paid or reserved claims, Contractor shall notify the Department within ten
(10) days and reinstate the aggregates required;
- Unlimited defense costs in excess of policy limits;
Contractual liability covering the indemnification provisions of this
Agreement;
A severability of interests provision;
Waiver of exclusion for lawsuits by one insured against another;
A provision that coverage is primary; and
A provision that coverage is non-contributory with other coverage or
self-insurance provided by the Department.
v.For all general liability, excess/umbrella liability, liquor liability, pollution liability and
professional liability policies, if the policy is a claims -made policy, the retroactive date
must be on or before the contract date or the first date when any goods or services were
provided to the Department, whichever is earlier.
c. Contractors shall secure and deliver to County's Risk Administrator ("Administrator") at
or before the time of execution of this Agreement, and shall keep in force at all times during the
term of the Agreement as the same may be extended as herein provided, a commercial general
liability insurance policy, including public liability and property damage, in form and company
acceptable to and approved by said Administrator, covering all operations hereunder set forth in
the related Bid or Request for Proposal.
d. Proof of Insurance: Contractor shall provide a copy of this information to its insurance
agent or broker and shall have its agent or broker provide proof of Contractor's required
insurance. The Department reserves the right to require Contractor to provide a certificate of
insurance, a policy, or other proof of insurance as required by the County's Risk Administrator in
his sole discretion.
e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal liability,
liquor liability, and inland marine, Contractor's insurer shall name County as an additional insured
as follows
f. Waiver of Subrogation: For all coverages, Contractor's insurer shall waive subrogation
rights against County.
g. Subcontractors: All subcontractors, independent contractors, sub -vendors, suppliers or
other entities providing goods or services required by this Agreement shall be subject to all of the
requirements herein and shall procure and maintain the same coverages required of Contractor.
Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers
or other entities as insureds under its policies or shall ensure that all subcontractors maintain the
required coverages. Contractor agrees to provide proof of insurance for all such subcontractors,
independent contractors, sub -vendors, suppliers or other entities upon request by the
Department.
A provider of Professional Services (as defined in the Bid or RFP) shall provide the following
coverage:
Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and
$2,000,000 aggregate limit for all claims.
10. Certification
Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all
necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies
covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the
Contractor prior to the start of any Agreement.
11. Training
Contractor may be required to attend training at the request of the Department specific to services
provided under this Agreement. The Department will not compensate the Contractor for said training in
the form of registration fees, time spent traveling to and from training, attending the training or any other
associated costs unless otherwise agreed to by the Department.
12. Subpoenas
Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the
Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For
this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the
Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will
contact the Weld County Attorney's Office immediately at 970-400-6503 and advise that the subpoena
must be personally served.
13. Monitoring and Evaluation
Contractor and the Department agree that monitoring and evaluation of the performance of this
Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and
evaluation shall be provided to the Board of Weld County Commissioners, the Department and the
Contractor.
Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service
delivery, service quality, documentation, and invoicing during referral period and after services have
concluded. The Contractor will require clients sign releases of information. Contractor understands that
the Department will not reimburse for services rendered to Department clients until releases of
information are obtained.
Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to
monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The
monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any
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program data, special analyses, on -site checking, formal audit examinations, or any other reasonable
procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not
unduly interfere with the work conducted under this Agreement.
14. Modification of Agreement
All modifications to this Agreement shall be in writing and signed by both parties.
15. Remedies
The Director of Human Services or designee may exercise the following remedial actions should s/he find
the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial
failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
- Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed.
- Deny payment or recover reimbursement for those services or deliverables, which have
not been performed and which due to circumstances caused by the Contractor cannot be
performed or if performed would be of no value to the Department. Denial of the amount
of payment shall be reasonably related to the amount of work or deliverables lost to the
Department.
- Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation
shall be recovered from Contractor by deduction from subsequent payments under this
Agreement or other agreements between the Department and Contractor, or by the
Department as a debt due to the Department or otherwise as provided by law.
16. Representatives
For the purpose of this Agreement, the individuals identified below are hereby designated representatives
of the respective parties. Either party may from time to time designate in writing a new or substitute
representative(s).
For Department: For Contractor:
Heather Walker, Child Welfare Division Head Doug Wenger, Director
17. Notice
All notices required to be given by the parties hereunder shall be given by certified or registered mail to
the individuals at the addresses set forth below. Either party may from time to time designate in writing a
substitute person(s) or address to whom such notices shall be sent.
For Department:
Judy A. Griego, Director
P.O. Box A
Greeley, CO 80632
(970) 400-6510
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For Contractor:
Doug Wenger, Director
323 East 27th Street
Loveland, CO 80538
(603) 361-7093
18. Litigation
Contractor shall promptly notify the Department in the event that Contractor learns of any actual
litigation in which it is a party defendant in a case that involves services provided under this Agreement.
Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading
which has been filed in any Federal or State court or administrative agency, shall deliver copies of such
document(s) to the Director of Human Services. The term "litigation" includes an assignment for the
benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure.
19. Termination
This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the
individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an
obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise
appropriated in each succeeding year, as this Agreement is subject to the availability of funding.
Therefore, the Department may terminate this Agreement at any time if the source of funding for the
services made available to the Contractor is no longer available to the Department, or for any other
reason. Contractor reserves the right to suspend services to clients if funding is no longer available.
20. No Third -Party Beneficiary Enforcement
It is expressly understood and agreed that the enforcement of the terms and conditions of this
Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the
undersigned parties and nothing in this Agreement shall give or allow any claim or right of action
whatsoever by any other person not included in this Agreement. It is the express intention of the
undersigned parties that any entity other than the undersigned parties receiving services or benefits
under this Agreement shall be an incidental beneficiary only.
21. Governmental Immunity
No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of
any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental
Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended.
22. Partial Invalidity of Agreement
If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held
or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions.
The parties hereto declare that they would have entered into this Agreement and each and every section,
subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more
sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional
or invalid.
23. Improprieties/Conflict of Interest
No officer, member or employee of Weld County and no member of their governing bodies shall have any
pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof.
The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department
when the Contractor also maintains a relationship with a third party and the two relationships are in
opposition. In order to create the appearance of a conflict of interest, it is not necessary for the
Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor
know that the two relationships are in opposition. During the term of the Agreement, Contractor shall
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not enter into any third -party relationship that gives the appearance of creating a conflict of interest.
Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the
Department, a full disclosure statement setting forth the details that create the appearance of a conflict
of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute
grounds for the Department's termination, for cause, of its Agreement with the Contractor.
A conflict of interest or appearance of a conflict of interest may also apply to personal relationships
between providers and clients. If a provider has a personal relationship with a client to whom the
Contractor may provide services for, the Contractor must disclose that relationship to the Department.
Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of
Contractor, to any person for influencing or attempting to influence an officer or employee of an agency,
a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with the awarding of any Federal contract, the making of any Federal grant, the making of any
Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal,
amendment, or modification of an Federal contract, loan, grant, or cooperative agreement.
24. Storage, Availability and Retention of Records
Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during
business hours, have access to inspect and copy records, and shall be allowed to monitor and review
through on -site visits, all activities related to this Agreement, supported with funds under this Agreement,
to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and
evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The
results of the monitoring and evaluation activities shall be provided to the appropriate and interested
parties.
All such records, documents, communications, and other materials created pursuant or related to this
Agreement shall be maintained by the Contractor in a central location and shall be made available to the
Department upon its request, for a period of seven (7) years from the date of final payment under this
Agreement, or for such further period as may be necessary to resolve any matters which may be pending,
or until an audit has been completed with the following qualifications: If an audit by or on behalf of the
Federal and/or State government has begun but is not completed at the end of the seven (7) year period,
or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until
the resolution of the audit finding.
25. Confidentiality of Records
Contractor shall protect the confidentiality of all applicant records and other materials that are
maintained in accordance with this Agreement except for purposes directly connected with the
administration of Child Protection. No information about or obtained from any applicant/recipient in
possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's
parent or guardian unless in accordance with the Contractor's written policy governing access to,
duplication and dissemination of, all such information, in any form, including social networks. Contractor
shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality
requirements.
Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written
explanation of these confidentiality requirements before access to confidential data is permitted.
Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality
agreement and shall provide a copy of such agreement to the Department, if requested.
11
26. Proprietary Information
Proprietary information for the purposes of this Agreement is information relating to a party's research,
development, trade secrets, business affairs, internal operations and management procedures and those
of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third
parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither
party shall use or disclose directly or indirectly without prior written authorization any proprietary
information concerning the other party obtained as a result of this Agreement. Any proprietary
information removed from the Department's site by the Contractor in the course of providing services
under this Agreement will be accorded at least the same precautions as are employed by the Contractor
for similar information in the course of its own business.
27. Independence of Contractor: Not an Employee of Weld County
Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees
will not become employees of County, nor entitled to any employee benefits from County as a result of
the execution of this Agreement. Contractor shall perform its duties hereunder as an independent
Contractor. Contractor shall be solely responsible for its acts and those of its agents and employees for all
acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to
unemployment insurance or workers' compensation benefits through County and County shall not pay for
or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment
insurance benefits will be available to Contractor and its employees and agents only if such coverage is
made available by Contractor or a third party. Contractor shall pay when due all applicable employment
taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement.
Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or
understanding, except as expressly set forth in this Agreement. Contractor shall have the following
responsibilities with regard to workers' compensation and unemployment compensation insurance
matters: (a) provide and keep in force workers' compensation and unemployment compensation
insurance in the amounts required by law, and as set forth in Exhibit A provide proof thereof when
requested to do so by County.
28. Entire Agreement
This Agreement, together with all attachments hereto, constitutes the entire understanding between the
parties with respect to the subject matter hereof, and may not be changed or modified except as state in
Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs,
legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or
obligations hereunder without the prior consent of both parties.
29. Agreement Nonexclusive
This Agreement does not guarantee any work, nor does it create an exclusive agreement for services.
30. Warranty
The Contractor warrants that services performed under this Agreement will be performed in a manner
consistent with the professional standards governing such services and the provisions of this Agreement.
The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training,
diligence and judgment provided by highly competent individuals and entities that perform services of a
similar nature to those described in this Agreement including Exhibits A, B, C, and D.
12
31. Acceptance of Services Not a Waiver
Upon completion of the work, the Contractor shall submit to the Department originals of all tests and
results, reports, etc., generated during completion of this work. Acceptance by the Department of reports
and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of
responsibility for the quality and accuracy of the services. In no event shall any action by the Department
hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or
default which may then exist on the part of the Contractor, and the Department's action or inaction when
any such breach or default shall exist shall not impair or prejudice any right or remedy available to the
Department with respect to such breach or default; and no assent, expressed or implied, to any breach of
any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a
waiver of any other breach. Acceptance by the Department of, or payment for, any services performed
under this Agreement shall not be construed as a waiver of any of the Department's rights under this
Agreement or under the law generally.
32. Employee Financial Interest/Conflict of Interest. C.R.S. §§24-18-201 et seq. and §24-50-507
The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any
personal or beneficial interest whatsoever in the service or property which is the subject matter of this
Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which
would in any manner or degree with the performance of the Contractor's services and the Contractor,
shall not employ any person having such known interests. During the term of this Agreement, the
Contractor shall not engage in any in any business or personal activities or practices or maintain any
relationships which actually conflicts with or in any way appear to conflict with the full performance of its
obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may
result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of
the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or
hold any such position which either by rule, practice or action nominates, recommends, supervises
Contractor's operations, or authorizes funding to the Contractor.
33. Board of County Commissioners of Weld County Approval
This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld
County, Colorado.
34. Choice of Law/Jurisdiction
Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation,
execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference
which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute
between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction
to resolve said dispute.
35. Subcontractors
Contractor acknowledges that the Department has entered into this Agreement in reliance upon the
particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor
agreements for the completion of this project without the Department's prior written consent, which may
be withheld in the Department's sole discretion.
13
36. Attorney's Fees/Legal Costs
In the event of a dispute between the Department and Contractor, concerning this Agreement, the parties
agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by
or on its own behalf.
37. Ownership
All work and information obtained by Contractor under this Agreement or individual work order shall
become or remain (as applicable), the property of the Department. In addition, all reports, documents,
data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement
and all reports, test results and all other tangible materials obtained and/or produced in connection with
the performance of this Agreement, whether or not such materials are in completed form, shall at all times
be considered the property of the Department. Contractor shall not make use of such material for purposes
other than in connection with this Agreement without prior written approval of the Department.
38. Interruptions
Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or
otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond
its reasonable control, including but not limited to Acts of God, fires, strikes, war, flood, earthquakes or
Governmental actions.
39. Severability
If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of
competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the
extent that this Agreement is then capable of execution within the original intent of the parties.
14
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and
year first above written.
COUNTY:
ATTEST: �j� f Jode,o;(o. BOARD OF COUNTY COMMISSIONERS
Weld C. n Clerk to the Board WELD COUNTY, COLORADO
By: L .-S :%.I►M?
Deputy Clerk tot Board 1
15
Barbara Kirkmeyer,
CONTRACTOR:
Heart -Centered Counseling
323 East 27th Street
Loveland, CO 80538
(603) 361-7093
By:
Date:
Doug N€n er(Apr 23, 2019)
Nit2019
Doug Wenger, Director
Apr 23, 2019
EXHIBIT A
WELD COUNTY'S REQUEST FOR PROPOSAL
(Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon
request to the Department.)
This page intentionally left blank.
EXHIBIT B
CONTRACTOR'S RESPONSE TO REQUEST FOR PROPOSAL
Heart -Centered Counseling
Weld County Department of Human Services Bid Introduction Letter:
Heart -Centered Counseling is seeking to partner with Weld County DHS to offer behavioral health
services, including counseling and medication management services.
Heart -Centered Counseling is one of Larimer and Weld County's largest outpatient mental health
groups. We now have about 126 therapists and thousands (1,000+) of different clients seen each
week. We have added eight med providers to our staff as well.
Heart -Centered Counseling now has 14 office locations, three in Weld County (located in the city
of Greeley) and seven in Larimer County, three in Loveland and four in Fort Collins. We also have
offices in Littleton, Castle Rock and Denver. Our group continues to grow to meet the demand of
the community, our clients and our referral sources, providing quality and timely care to those in
need.
Heart -Centered Counseling makes the following commitments to the communities it serves in an
effort to be able to meet the community's mental health needs, to be responsive to client's needs
and be able to quickly get clients scheduled for services that they need:
1. Immediate Availability: We understand that when individuals or referring agencies call for
Mental Health support, the need is almost always immediate. For this reason, whenever a client
needs to be seen quickly, we get over 90% of our clients scheduled for appointments scheduled
within 7 days.
2. Acceptance of Medicaid, Medicare, and all Commercial Insurances: We accept all major
insurances, including Medicaid, Medicare, and private commercial insurance plans such as those
offered through BC/BS, United, Cigna, Beacon, Tricare, Aetna, Kaiser and so on, as well as a
number of EAP programs including Mines and Associates, Morneau Shepell and more.
3. Coverage for all areas of Behavioral Health: We work with children as young as 1 and adults
of all ages, including the elderly, couples, and families. We offer support for the wide spectrum of
mental health issues, ranging from trauma, to substance abuse, to anxiety and depression, to
eating disorders, to you -name -it. And we have therapists that deliver a wide variety of modalities
and specialties, including EMDR, accu detox, and neuro feedback.
4. Experienced Care: A large percentage of our therapists have over 10 years of experience, and
many have over 30. We pride ourselves in offering experienced clinical care and have an in-house
training program that covers ethics and ongoing clinical training to ensure our therapists remain
both experienced and engaged.
5. Coordination of Care: We provide a weekly report on any new referrals, letting you find out
what happened when we reached your client to schedule an appointment. We also offer monthly
treatment updates which share information such as frequency of visits and progress in therapy.
6. We have added more Nurse Practitioners to allow us to better serve the needs of our
community in terms of medication management.
EXHIBIT B
PROVIDER INFORMATION FORM
Weld County Department of Human Services
Heart Centered Counseling
AGENCY OR PRIVATE PRACTICE 'RATS PROVIDER ID(!`. Known)
Doug Wenger
PRIMARY CONTACT - FULL NAME
(603) 361-7093
PHONE NUMBER
Doup@heartcenteredcsunselorscom
PRIMARY CONTACT- E-MAIL ADDRESS
323 E 27th St
AGENCY MAILING ADDRESS
Director
PRIMARY CONTACT - TITLE
(888) 965-4615
EXT. FAX NUMBER
htto // heartcenteredcounselors.cmn
AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE)
Loveland
CITY
80538
ZIP
REFERRAL CONTACT
Ginger K:ein and Ann Mullano FCT Director and FCT Assistant Director
REFFERAL CONTACT - FULL NAME REFERRAL CONTACT - TITLE
970-310-3406 gingerk5aheartcenteredcounse)ars corn annma@heartcenteredcounselorscorn
REFERRAL CONTACT- PHONE NUMBER
EXT. REFERRAL CONTACT - E-MAIL ADDRESS
BILLING CONTACT
Carla Amarillo
BILLING CONTACT - FULL NAME
(970) 372.6625
BILLING CONTACT - PHONE NUMBER
EXT.
Insurance Team Director
BILLING CONTACT - TITLE
msuranceteamYoheartcenteredcounsetors.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:
Date of Signature: 1/2 4 1 I 't
r
Bid No.: B1900025
EXHIBIT C
PROPOSAL TEMPLATE
1. Bidder's legal entity name:
2. Program name or service type
being proposed:
Heart Centered Counseling
Outpatient Mental Health Counseling, Psychological Testing and
Medication Management.
3. Modalities, curriculum or tools
that will be utilized in the delivery of the service.
Outpatient Psychotherapy for MH and SUD Issues that Includes:
• Individual Therapy, Utilizing a combination of:
o Cognitive Behavioral Therapy (CBT)
o Motivational Interviewing
o Person Centered Therapy
o EMDR
o Trauma Focused — Cognitive Behavioral Therapy TF-CBT
o Dialectical Behavioral Therapy
o Play Therapy
o Acceptance and Commitment Therapy
o Harm Reduction
o Gottman
o Narrative Therapy
• Couples
o Emotionally Focused Therapy
o Gottman
• Family Therapy
• Group Therapy
o Dialectical Behavioral Therapy
o Seeking Strength/Safety
Assessments
• Diagnostic psychological assessment -ADHD assessment
• Learning Disability assessment -Autism assessment;
• Substance use disorder evaluations -neuro-psych evaluations
Medication Management Services
• Initial medication evaluations
• Ongoing medication management services
Neuro-Psychological Testing/Evaluations
• Administer psychological evaluations/testing
• Interpretation of psychological evaluations/testing
4. Capacity to Provide Services (ex. 4 hours/week).
• Our offices see clients as early as 7:30am and as late as 8pm Monday - Friday. Some weekend
availability is offered, on Saturdays. We currently have 126 therapists, 8 nurse practitioners and
thousands (1,000+) of different clients seen each week. Heart -Centered Counseling now has 14
office locations, three in Weld County (located in the city of Greeley) and seven in Larimer County,
with three in Loveland and four in Fort Collins. We also have offices in Littleton, Castle Rock and
Bid No.: 1900025
EXHIBIT C
PROPOSAL TEMPLATE
Denver. Our group continues to grow to meet the demand of the community, our clients and our
referral sources, providing quality and timely care to those in need.
5. Goals of the service.
• Our primary goal at Heart Centered Counseling is to help all individuals recover from mental health
and substance use disorder issues. We strive to offer the best care and provide people with long
lasting change. We are a trauma informed practice group. We recognize the impact trauma has on
individuals and how this can shape their mental health and substance use disorder issues. We offer
clients therapy that meets their needs to help them recover from and heal trauma.
• Immediate Availability: We understand that when individuals or referring agencies call for Mental
Health support, the need is almost always immediate. For this reason, whenever a client needs to
be seen quickly, we get 90% of our clients scheduled within one week.
6. Outcomes of service.
• At Heart Centered Counseling we are committed to providing excellent mental health and
substance use disorder treatment. This is evidenced by the fact that 89% of the time our client's
return after the first session.
• Our commitment to excellence starts at the first phone call from the client. Over 90% of the time
we are able to offer a client their initial appointment within 7 days.
• It is routine HCC clinical practice to offer its clients at least 4 appointments within 45 days of the
first session but we have not tracked this data point specifically. HCC therapists typically schedule
one appointment per week for clients early in the therapeutic process. However, not all clients are
able or interested to meet this frequently. If requested by Weld DHS, we will track this
performance indicator for CORE referrals.
• We offer ongoing clinical supervision and consultation for all of our therapists in order to help our
clinicians hone their therapeutic skills in order to best serve our clients.
7. Target population for service.
Note: Please include age range, applicable genders, and any specific characteristics/traits/needs.
• Young Children
• Adolescents
• Adults (young, middle-aged, and elderly) — Couples
• Families
8. Service access.
Note: Bidder must indicate capacity for video conferencing, phone conferencing and in person.
If office -based, bidder should provide full physical addresses for all locations. If provided outside the
office, bidder should note home -based and/or community -based, and geographical area(s) bidder is
willing to travel to.
• We offer in person psychotherapy and medication management. With locations in Greeley,
Loveland, and Fort Collins.
o Our Greeley Offices are located at:
• 1770 25th Ave Suite 206
• 1770 25th Ave Suite 202
• 1013 37th Ave Ct Suite 101
o Our Loveland Offices are located at:
Bid No.: 1900025
EXHIBIT C
PROPOSAL TEMPLATE
1032 N Lincoln Ave
• 1413 W 29th St
• 323 East 27th St
o Our Fort Collins Offices are located at:
• 320 W Olive St
• 1525 Riverside Ave
• 1531 Riverside Ave
• 1537 Riverside Ave
❑ Our Littleton Office are located at:
• 5911 S Middlefield Rd, Suite 100
• 5911 S. Middlefield Rd, Suite 200
❑ Our Denver Office is located at:
• 950 E Harvard Ave, Suite 670
❑ Our Castle Rock Office is located at:
• 410 S. Wilcox Street
• We also offer tele therapy and medication management through secure video conferencing. We
have partnered with various doctors' offices in communities to offer integrated tele therapy to help
individuals located in rural areas where broadband may not be as accessible.
9. Languages service is available in.
Note: Bidder should note the language and level of proficiency.
• Proficiency in English and Spanish.
10. Rates of Service.
Note: Bidder should include fee for service, staffing, mileage, and any other applicable costs bidder
would like considered. Rates must be an exact amount and must include the unit of cost (i.e., hour, day,
month, episode). Approximate rates or a range of rates for a service will not be accepted.
• Outpatient Psychotherapy - Master's Level practitioner $85 per hour, Ph. D. Level practitioner $93 per
hour.
• Assessment - $95 per hour. Duration of any assessment can be discussed on a case -by -case basis
prior to the start of any work.
• Medication Management - $150 for initial Medication Evaluation appointment; $95 for 30min
medication management; $65 for 15min medication management.
• Neuro-Psychological Evaluations - $120 per hour.
Bid No.: 1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeeD(4081E0 One Staff Data Sheet per proposed service. Bidder should not combine services.)
PROPOSED SERVICE OR SERVICE TYPE:
Outpatient Mental Health Counseling, Psychological Testing and Medication Management.
BIDDER LEGAL ENTITY NAME:
Heart Centered Counseling
APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION '.
No.
Last Name
First Name
Work#
Work Email .
Education
Level" ,
Degree Focus , ,
Licensure/ •
Credentials `
DORA"#
(If applicable)
1
Alieksaites
Jodi
720-295-1845
jodi@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0013030
2
Bagwell
Stephanie
720-507-7686
stephanie@heartcenteredcounselors.com
Doctor of Psychology
Psy
PSY. 0004599
3
Baker
Elissa
970-371-8911
elissa@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0005535
4
Barou
Daniela
970-426-0452
danielab@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 09924910
5
Barr
Thomas
303-664-5281
tom@heartcenteredcounselors.com
Doctor of Psychology
Ph.D
PSY.0002160
6
Beals
Dena
970-414-0656
denab@heartcenteredcounselors.com
Masters of Arts
LMFT
MFT. 0001561
7
Blocksma
Douglas
970-414-0210
douglas@heartcenteredcounselors.com
Bachelor of Science
LPC
LPC. 0012484
8
Bolint
Susan
970-829-8804
sue@heartcenteredcounselors.com
Masters of Arts
LMFT, LAC
MFT. 0001049
9
Bomberg
Ann
720-442-4506
annieb@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.00993043
10
Boyer
Tammy
970-449-3431
tammy@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.00002092
11
Burnett
Jennifer
970-324-4976
jen@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW. 09923444
12
Burton
John
970-939-4488
johnb@heartcenteredcounselors.com
Doctor of Education
LPC, EdD
LPC. 0015153
13
Castillo
Jamie
970-541-9307
jamie@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0013275
14
Chavez
Cynthia
970-584-6365
cynthia@heartcenteredcounselors.com
Masters of Arts
LPC,MA,CACII
LPC. 0014138
15
Collinsworth
Cindy
720-504-7387
cindyc@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0012492
16
Conner
Abbie
970-460-8019
abbie@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.09923028
17
Cowan
Krista
970-381-3388
kristac@heartcenteredcounselors.com
Masters of Arts
LPC, LAC
ACD. 0000430
18
Davis
Alyssa
970-402-6238
alyssadavis@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0013522
19
De la Torre
Alyssa
970-305-4101
alyssa@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0014051
20
Diamond
Carole
970-581-3802
caroled@heartcenteredcounselors.com
Masters of Arts
PMHNP-BC, NP -C
RN. 0130431
21
Dimmen-Klenk
Amanda
970-400-1953
amanda@heartcenteredcounselors.com
Master of Science
LMFT
MFT. 0001447
22
Edsall
Deborah
970-590-0590
deborahe@heartcenteredcounselors.com
Doctor of Science
LPC
LPC. 0003229
23
Edwards
Janis
970-617-5990
janise@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW. 09924789
24
Eells
Stephanie
720-254-0494
shephaniee@heartcentercounselors.com
Master of Science
LPC, DBTC
LPC.0001245
25
Engelman
Blake
970-829-8732
blake@heartcenteredcounselors.com
Licensed Professional Coun
LPC
LPC. 0013480
26
Falcao
Genesa
720-582-3570
genesa@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0012470
27
Flint
Velvet
719-691-9765
velvetf@heartcenteredcounselors.com
Master of Science
LPC
LPC. 0011809
28
Flores
Denise
805-798-1370
denise@heartcenteredcounselors.com
Master of Science
LMFT
MFT. 0001465
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeekitifigeeD One Staff Data Sheet per proposed service. Bidder should not combine services.)
29
Foley
Suzanne
970-344-9905
suzanne@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0012508
30
Ford
Haley
978-709-1309
haley@heartcenteredcounselors.com
Doctor of Philosophy
Ph.D
PSY. 0004641
31
Friese
Ariel
312-952-7901
ariel@heartcenteredcounselors.com
Master in Counseling
LPC
LPC.0011347
32
Garcia
Monica
925-337-0415
monica@heartcenteredcounselors.com
Doctor of Psychology
Psy.D
PSY. 0004741
33
Gardner
Lawrence
804-869-5981
lee@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.09925369
34
Gastel
Rosalyn
909-379-4700
rosalyng@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 09925434
35
Gentry
Deborah
281-961-7838
debbie@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 09924057
36
Gills
Gina
720-318-8866
ginag@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 00001221
37
Graber
Justine
720-509-9869
justineg@heartcenteredcounselors.com
Masters of Arts
LPC, LMFT, LAC
MFT. 0001294
38
Green
Sarah
970-373-5246
sarahg@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.09925660
39
Grossman
Joseph
970-301-1089
joe@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0013556
40
Hand
Amanda
970-795-2144
amandah@heartcenteredcounselors.com
Masters of Arts
MNM, LPC
LPC. 0003930
41
Healy
Amy
970-612-8588
amy@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW. 09925162
42
Hedrick
Jami
720-772-0592
jamih@heartcenteredcounselors.com
Master in Counseling
LPC
LPC.0006110
43
Herom
Pedar
970-579-0634 .
pedarh@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0014313
44
Herrick
Pamela
949-680-7878
pamelah@heartcenteredcounselors.com
Masters of Arts
LMFT
MFT. 0001552
45
Hessel
Laurie
970-214-2834
laurieh@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW. 00989158
46
Hotchkiss
Roxanne
720-924-6615
roxanneh@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.09923625
47
Huemmler
Johanna
970-795-2825
jojoh@heartcenteredcounselors.com
Master of Science
LMFT
MFT. 0001450
48
Inglis
Sharon
720-257-9212
sharoni@heartcenteredcounselors.com
Masters of Arts
LCSW
CSW.00000781
49
lzmirian
Sonia
608-561-1576
soniai@heartcenteredcounselors.com
Doctor of Philosophy
Ph.D
PSY.0004874
50
Jansen
Kristin
970-599-1405
kristinj@heartcenteredcounselors.com
Masters of Arts
LPC, LAC
LPC. 0002745
51
Jones
Cheyenne
970-673-7869
cheyennej@heartcenteredcounselors.com •
Master in Counseling
LPC
LPC. 0014925
52
Kipp
Ginger
720-316-7482
gingerk@heartcenteredcounselors.com
Masters of Arts
LPC
LPC.0002132
53
Kraemer
Sharlene
941-524-0842
cheryk@heartcenteredcounselors.com
Masters of Science in educe
LPC
LPC.0013471
54
Le Pont -Fowler
Jennifer
970-430-6113
jenniferl@heartcenteredcounselors.com
Psychiatric/Mental Health
DNP
APN. 0993608
55
Leaderman
Alexandra
415-940-1428
aexandra@heartcenteredcounselors.com
Master in Counseling
LPC
LPC. 0014269
56
Lohse
Lauri
970-660-8098
lauri@heartcenteredcounselors.com
Registered Nurse
ARNP
RN.1655161
57
Lutz
James
303-653-6901
jim@heartcenteredcounselors.com
Masters of Arts
Ed.D.,LPC
LPC. 0012648
58
Mavrides
Gregory
970-617-4020
greg@heartcenteredcounselors.com
Doctor of Philosophy
PhD
CSW. 09925008
59
McDonald
Emily
970-834-3699
emilym@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0013862
60
McDonell
Rena
970-658-8899
rena@heartcenteredcounselors.com
Masters of Science
LPC
LPC.0013582
61
McGuire
Terry
720-432-7553
terrym@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.00991055
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeektddlit® One Staff Data Sheet per proposed service. Bidder should not combine services.)
62
Meisinger
Tracy
970-581-0980
tracym@heartcenteredcounselors.com
Master in Counseling
MFT, LPC, NCC
LPC.0015101
63
Morse
Angelica
720-446-6659
angelica@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.09923929
64
Musial
Stacy
970-236-1866
stacy@heartcenteredcounselors.com
Master of Social Work
MSW,LCSW
CSW. 09923929
65
Nabers
Lance
512-578-5283
lancen@heartcenteredcounselors.com
Master of Science
LPC
LPC. 0013506
66
Neves
Hali
307-272-1132
hali@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0014207
67
Oxton
Adrian
218-329-1762
adrian@heartcenteredcounselors.com
Masters of Arts
LPC, LAC
LPC. 0011495
68
Paroz
Natala
505-401-2199
natala@heartcenteredcounselors.com
Master of Social Work
Masters of Arts
MSW, LCSW
CSW.09924711
69
Pike
Molly
720-863-6373
mollyp@heartcenteredcounselors.com
LPC
LPC. 0013686
70
Popescu
Cezar
632-693-4921
cezarp@heartcenteredcounselors.com
Masters of Arts
LPC
LPC.0014341
71
Preston
Mary
970-541-9534
mary@heartcenteredcounselors.com
Masters of Arts
LMFT
MFT. 0001310
72
Preston
Nathan
808-282-8323
nathan@heartcenteredcounselors.com
Masters of Arts
LMFT
MFT. 0001302
73
Price
Kathryn
720-695-1414
kathryn@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW.09923689
74
Pucciarello
Andrea
303-524-0050
andrea@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW. 00001128
75
Rauls
Charity
720-507-4543
charityr@heartcenteredcounselors.com
Masters of Arts
LPC
LPC. 0014151
76
Reid
Laura
970-573-7593
laura@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 09924105
77
Reisen
Mira
970-400-1432
mirar@heartcenteredcounselors.com
Master of Science
LMFT
MFT. 0001533
78
Kershner-Rice
Kendall
303-332-7752
kendallr@heartcenteredcounselors.com
Doctor of Philosophy
Ph.D
PSY. 0004886
79
Rogers
Adrienne
970-823-2875
adrienner@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 09925436
80
Roney
Christopher
217-649-8719
chrisr@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 09924221
81
Ross
Dalton
720-819-6354
daltonr@heartcenteredcounselors.com
jayr@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW. 00000151
82
Ryser
Jay
720-443-2791
Master in Counseling
MEd, LPC
LPC.0002457
83
Schwintosky
Brittani
720-432-5587
brittani@heartcenteredcounselors.com
Master of Science in Nursin
APN
0000783 C -NP
84
Scofield
Mark
970-683-0775
mark@heartcenteredcounselors.com
Master of Social Work
LCSW
LCSW.991945
85
Sehr
David
970-310-3406
davidsPheartcenteredcounselors.com
Doctor of Medicine
Masters of Arts
MD
DR.0048058
86
Shelstad
Brody
720-625-0747
brodys@heartcenteredcounselors.com
LMFT
MFT.0001582
87
Shirk
Kimberly
970-880-1429
kims@heartcenteredcounselors.com
Masters of Arts •
LPC, NCC
LPC.0014091
88
Stanley
Lauren
832-725-3636
laurens@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW.09924274
89
Stillman
Melissa
954-254-3760
melissas@heartcenteredcounselors.com
Master of Science and Educ
Masters of Arts
M.S.Ed., LPC
LPC.0013200
90
Stuart
Tracy
720-947-9590
tracys@heartcenteredcounselors.com
LPC
LPC.0012188
91
Talarico
Linda
908-472-0943
lindatalarico@heartcenteredcounselors.com
Clinical Social Worker
LCSW
CSW.09925185
92
Thompson
Marcella
530-949-5162
marcellat@heartcenteredcounselors.com
Master of Social Work
LCSW
CSW.09925635
93
Torvik
Molly
970-372-4456
molly@heartcenteredcounselors.com
abbeyt@heartcenteredcounselors.com
Master of Science
MSN, FNP-C
APN.0993750-NP
94
Towe
Abigail
970-364-6177
Master of Science in Nursin
MSN, FPMHNP- BC
C-APN.0001182
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposer9C 0We One Staff Data Sheet per proposed service. Bidder should not combine services.)
95
VanderBeek
Christina
970-310-8876
christina@heartcenteredcounselors.com
Masters of Arts
LPC
LPC.0013638
96
VanDerWerff
Jay
970-460-6219
jay@heartcenteredcounselors.com
Master of Social Work
LCSW, LAC
ACD.0000765
97
Voelsing
Kathleen
970-302-3434
KathleenV@heartcenteredcounselors.com
Other Degree
PMHNP-BC, DNP
APN.0990685-NP
98
VoVillia
Jeffery
303-847-9172
jeff@heartcenteredcounselors.com
Masters of Arts
LPC
LPC.0012765
99
Walk
Caitlin
970-699-5277
caitlin@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW.09925112
100
Watt
Kathryn
970-880-1654
katyw@heartcenteredcounselors.com
Masters of Arts
LPC
LPCC.0014880
101
Weitzel
Michael
970-420-2586
michael@heartcenteredcounselors.com
Masters of Arts
LPC
LPC.0005152 •
102
Wells
Cindy
720-989-5695
cindywells@heartcenteredcounselors.com
Master of Science
LPC
LPC.0002616
103
Wenger
Douglas
603-361-7093
doug@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW.09923897
104
White
Angela
970-829-8568
angela@heartcenteredcounselors.com
kenw@heartcenteredcounselors.com
Master in counseling
LPC,CACIII
ACB.0008153
105
Whitney
Ken
720-900-2106
Master of Social Work
MSW, LCSW
CSW.00993005
106
Wilson
Rebecca
720-739-0639
rebecca@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW.00001376
107
Wilson
Thomas
970-930-1264
thomasw@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW.09925447
108
Woods
Allison
720-979-7725
allison@heartcenteredcounselors.com
Licensed of Professional Co
LPC
LPC.0006336
109
Woods
LeAnn
928-451-1780
leann@heartcenteredcounselors.com
Masters of Arts
LPC
LPC.0013282
110
Wooldridge
Susan
802-760-7946
susanw@heartcenteredcounselors.com
Bachelor of Arts
LPC
LPC.0014424
111
Wurst
Amanda
303-325-4047
amandaw@heartcenteredcounselors.com
Master of Social Work
MSW, LCSW
CSW.00001505
Bid No.: 81900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeRiXitaiiND One Staff Data Sheet per proposed service. Bidder should not combine services.)
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposedd MiE® One Staff Data Sheet per proposed service. Bidder should not combine services.)
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeirbditthadD One Staff Data Sheet per proposed service. Bidder should not combine services.)
SUPERVISEE CANDIDATE/INTERN INFORMATION.
Cast Name "
First Name . „
Work IS
Work Email-
Education . •
Level -
Degree Focus:
Licensure/-
Credentials. .
DORA # •
(If applicable) ,-'
Ball
Caleb
970-829-8879
calebb@heartcenteredcounselors.com
MA
LPCC
LPCC.0015197
Benz
Jonathan
260-460-7786
jonathan@heartcenteredcounselors.com
MA
LPCC
LPCC.0015274
Chabrier
Joel
480-272-0543
joelc@heartcenteredcounselors.com
MA
LPCC
LPCC.0016220
Dauk
Nadara
970-541-9678
nadarad@heartcenteredcounselors.com-
MA
LPCC
LPCC.0015943
Jones
Lilla
970-460-4136
lillaj@heartcenteredcounselors.com
MA
LPCC
LPCC.0015850
Kintzley
Mari
303-249-4024
marik@heartcenteredcounselors.com
Bachelors
Counseling
Intern
NA
Long
Matthew
970-430-6751
matthewl@heartcenteredcounselors.com
MSW
LSW
LSW.0009922041
Nard
Laurel
970-425-3987
laureln@heartcenteredcounselors.com
MA
LPCC
LPCC.0015874
Nicholson
Janell
650-224-2718
janelln@heartcenteredcounselors.com
MA
LPCC
LPCC.0016109
Norris
Chelsea
970-775-8455
chelsean@heartcenteredcounselors.com
MA
LPCC
LPCC.0015786
Roberson
Taylor
843-503-1630
taylorr@heartcenteredcounselors.com
MA
LPCC
LPCC.0016031
Rodriguez
Meghan
970-424-4068
meghanr@heartcenteredcounselors.com
MS
LPCC
LPCC.0015229
Shiveley
Jessica
970-541-1015
jessicas@heartcenteredcounselors.com
MSW
LSW
LSW.0009921972
Suljovic
Daira
970-795-2903
dairas@heartcenteredcounselors.com
Bachelors
Counseling
Intern
NA
Asbury
Hope
970-400-1228
hopea@heartcenteredcounselors.com
Bachelors
Social Work
Intern
NA
Bid No.: 81900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposef:MIM 4 One Staff Data Sheet per proposed service. Bidder should not combine services.)
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the propose® One Staff Data Sheet per proposed service. Bidder should not combine services.)
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the propose@D(4tilfi4i One Staff Data Sheet per proposed service. Bidder should not combine services.)
Bid No.: B1900025
STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeEKIMND One Staff Data Sheet per proposed service. Bidder should not combine services.)
Bid No.: B1900025
HEALTHCARE PROVIDERS SERVICE
ORGANIZATION PURCHASING GROUP •1—IPSE
CNA
Certificate of Inourance
CLAIMS MADE POLICY FORM Print Date: 12/14/2018
Your professional liability insurance is written on a claims made basis and provides coverage for those claims which are
the result of medical incidents occurring subsequent to the prior acts date stated and which are first made against you
while this insurance is in force. Please discuss with your program Administrator.
Producer Branch Prefix Policy Number
018098 970 HPG 0622028318
Named Insured and Address:
Heart -Centered Counseling, Inc.
320 W Olive St
Fort Collins, CO 80521-2716
Medical Specialty:
Licensed Professional Counselor Firm
Excludes Cosmetic Procedures
Prior Acts Date: 01/01/16
Policy Period
from 01/01/19 to 01/01/20 at 12:01 AM Standard Time
Program Administered by:
Healthcare Providers Service Organization
1100 Virginia Drive, Suite 250
Fort Washington, PA 19034
1-888-288-3534
www.hpso.com
Code: Insurance is provided by:
80723
American Casualty Company of Reading, Pennsylvania
333 S. Wabash Avenue, Chicago, IL 60604
Professional Liability $1,000,000 each claim
Your professional liability limits shown above include the following:
* Good Samaritan Liability * Malplacement Liability * Personal Injury Liability
* Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit
Coverage Extensions
License Protection
Defendant Expense Benefit
Deposition Representation
Assault
Includes Workplace Violence Counseling
Medical Payments
First Aid
Damage to Property of Others
Information Privacy (HIPAA) Fines and Penalties
General Liability
General Liability
Fire & Water Legal Liability
Total: $52,062.00
$ 3,000,000 aggregate
$ 25,000 per proceeding $ 25,000 aggregate
$ 1,000 per day limit $ 25,000 aggregate
$ 10,000 per deposition $ 10,000 aggregate
$ 25,000 per incident $ 25,000 aggregate
$ 25,000 per person $ 100,000 aggregate
$ 10,000 per incident $ 10,000 aggregate
$ 10,000 per incident $ 10,000 aggregate
$ 25,000 per incident $ 25,000 aggregate
$1,000,000 each claim / $3,000,000 aggregate
Included in the GL limit shown above subject to $250,000 aggregate sublimit
Base Premium $52,062.00
Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and
endorsements.)
G -121500-D G -123815-A05 G -121502-C G -145184-A
GSL15565 GSL17101 GSL13424 GSL13425
CNA81758 CNA82011 CNA79575 G -121504-C
G -141235-A
Chairman of the Board
G -141230-A (03/2010)
q s.
Secretary
Coverage Change Date:
G -147292-A
CNA80052
G -123827-B
GSL15563
G -123846-005
G -123828-B
GSL15564
CNA81753
G -141231-A
Keep this document in a safe place.lt
and proof of payment are your proof of
coverage. There is no coverage in force
unless the premium is paid in full.ln order
to activate your coverage, please remit
premium in full by the effective date of
this Certificate of Insurance.
Master Policy # 188711433
Endorsement Change Date:
POLICY FORMS & ENDORSEMENTS
The following are the policy forms and endorsements that apply to your current professional liability insurance policy.
COMMON POLICY FORMS & ENDORSEMENTS
FORM # DESCRIPTION
G -121500-D Common Policy Conditions
G -123815-A05 State Endorsement
G -121502-C Claims Made Policy Form
G -145184-A Policyholder Notice - OFAC Compliance Notice
G -147292-A Policyholder Notice - Silica, Mold & Asbestos Disclosure
GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs
GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion
GSL15565 Healthcare Providers Professional Liability Assault Coverage
GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies
GSL13424 Services to Animals
GSL13425 Business Owner Coverage Extension Endorsement
CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement
G -123846-005 Colorado Cancellation and Non -Renewal
CNA81753 Coverage & Cap on Losses from Certified Acts Terrorism
CNA81758 Notice - Offer of Terrorism Coverage & Disclosure of Premium
CNA82011 Related Claims Endorsement
CNA79575 Exclusion of Cosmetic Procedures
G -121504-C General Liability Form
G -123827-B (02) Additional Insured General Liability
G -123828-B Certificate Holder
G -141231-A Additional Insured Healthcare Entity
G -141235-A Additional General Liability Locations
PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC
TO YOUR STATE AND YOUR POLICY PERIOD.
For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance
Guaranty Association.
For KY residents:
The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement
Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which
includes charges at a municipality and/or county level.
For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge.
For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association
- 2012 Regular Assessment.
Form#: G -141230-A (03/2010)
Named Insured: Heart -Centered Counse
Master Policy#: 188711433 Policy#: 0622028318
Heart Centered Counseling
320 West Olive St.
Fort Collins, CO 8o521-2716
11/29/2018
To: Beacon Health Options
Re: Group Malpractice
This letter is to confirm that the following providers are covered under our
Group Malpractice Insurance with Policy number 0622028318 for the policy
period 01/01/2018 through 01/01/2019.
Thank you.
Sincerely,
Carla Eliza. Amarillo
Heart Centered Counseling
Insurance' Claims' Benefits 'Payroll' Beacon and Humana
Email: carla@heartcenteredcounselors.com
Text Message: 970-329-5195
Phone: 970- 372-6625
Fax: 970-516-0655
Jodi Alieksaites, MA,LPC
Stephanie Bagwell, Psy.D.
Elissa Baker, MA, LPC
Daniela Barou
Thomas Barr
Dena Beals
Veronica Bechara, LCSW
Jonathan Benz, M.A., LPCC
Douglas Blocksma, MA, NCC, LPC
Susan Bolint, MS, M.Ed., LMFT, LAC
Ann Bomberg
Tammy Boyer
Jennifer Burnett, MSW, LCSW
John Burton
Alison Butler, MA, LPC, NCC
Lesley Caldwell, LPC
Laurel Carter, MA, LPC
Jamie Castillo, M.A., LPC
Sharon Cleveland
Cynthia Chavez, LPC,MA,CACII
Cynthia Collinsworth
Abbie Conner, MSW, LCSW
Krista Cowan
Nadara Dauk
Alyssa Davis
Alyssa De La Torre
Carole Diamond
Amanda Dimmen-Klenk, M.S., LMFT
Deborah Edsall
Janis Edwards
Blake Engelman, M.A., LPC
Genesa Falcao, LPC
Velvet Flint, LPC
Denise Flores, LMFT
Suzanne Foley, LPC
Haley Ford, Ph.D.
Ariel Friese, MC, LPC
Monica Garcia, Psy.D.
Deborah Gentry, MSW, LCSW
Amanda Hand, MA, MNM, LPC
Ginger Kipp
Amy Healy Krumwiede
Jami Hedrick
Pedar Herom, MA, LPC
Michael Herr
Pamela Herrick
Laurie Hessel, MSW, LCSW
Diane Holliday, Masters Candidate
Johanna Huemmler
Linne Humbargar, MMS, PA -C
Sharon Inglis
Sonia lzmirian
Kristin Jansen
Katelyn Johnson
Cheyenne Jones
Mari Kintzley
Sharlene Kraemer
Jennifer Le Pont -Fowler, DNP
Alexandra Leaderman, MA, LPC
Dori Lewis, MA,Ed M, LPC
Lauri Lohse, ARNP
Matthew Long
James Lutz
Emily Mcdonald
Gregory Mavrides, PhD
Rena Mcdonell
Terry Mcguire
Tracy Meisinger
Cheryl Mlcoch, M.S., LPC
Kathryn Monnig, MA, LPC
Kelsey Morrow Wright
Angelica Morse, LCSW
Stacy Musial
Laurel Nard
Lance Nabers
Hali Neves, MA, LPC
Janell Nicholson
Chelsea Norris
Adrian Oxton, MA, LPC, LAC
Natala Paraz, MSW, LCSW
Mary Pike
Anne Poler, MA, LCSW
Cezar Popescu
Mary Preston, LMFT
Nathan Preston, LMFT
Kathryn Price, MSW, LCSW
Andrea Pucciarello, MSW,
LCSW Laura Reid, LCSW
Charity Rauls
Mira Reisen
Jay Ryser
Kendall Kershner Rice
Christopher Roney
Taylor Roberson
Meghan Rodriguez
Adrienne Rogers
Valeria Rojo
Dalton Ross
Amy Ryk
Holly Schubert
Brittani Schwintosky, APN
Mark Scofield
David Sehr
Brody Shelstad
Kimberly Shirk
Jessica Shiveley, LSW
Max Stager, MA, LPC, NCC
Lauren Stanley, MSW, LCSW
Melissa Stillman, M.S.Ed., LPC
Tracy Stuart, LPC
Daira Suljovic
Linda Talarico, MSW, LCSW
Marcella Thompson, LCSW
Molly Torvik, MSN, FNP-C
Abigail "Abbey" Towe
Stephen A. Valente, MSW, LCSW
Christina VanderBeek, MA,LPC
Jay VanDerWerff, MSW, LCSW, LAC
Kathleen Voelsing
Jeffrey Vovilla
Caitlin Walk
Milena Walkowiak
Kathryn Watt
Michael Weitzel
Cindy Wells
Douglas Wenger
Angela White
James Kenneth Whitney
Rebecca Wilson, MSW,
Thomas Wilson
Allison Woods, LPC
(Policy Provisions: WC000000C)
INFORMATION PAGE
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: Trumbull Insurance Company
ONE HARTFORD PLAZA HARTFORD CT 06155
NCCI Company Number:
Company Code: H
19666
POLICY NUMBER:
Previous Policy Number:
76 WEG 1O8418
76 WEG 1O8418
1. Named Insured and Mailing Address: HEART CENTERED COUNSELING INC
(No., Street, Town, State, Zip Code) 320 W OLIVE ST
FORT COLLINS CO 80521
FEIN Number: 45-2668894
State Identification Number(s):
The Named Insured is: Corporation
Business of Named Insured: Offices of All Other Miscellaneous Health Practitioners
Other workplaces not shown above:
2. Policy Period: From 01/11/19 To 01/11/20 ANNUAL
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: AUTOMATIC DATA PROCESSING INS AGCY
1 ADP BLVD M/S 625
ROSELAND NJ 07068
Producer's Code: 76250873
Issuing Office: THE HARTFORD BUSINESS SERVICE CENTER
3600 WISEMAN BLVD
SAN ANTONIO TX 78251
(877) 287-1316
THE
HARTFORD
Suffix
LARS RENEWAL
3
Total Estimated Annual Premium: $7,762
Deposit Premium:
Policy Minimum Premium: $326 CO (Includes Increased Limit Min. Prem.)
Audit Period: ANNUAL Installment Term: Four Pay (30%Down+2@25%+1@20%)
The policy is not binding unless countersigned by our authorized representative.
Countersigned by
12/02/18
Authorized Representative Date
Form WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 12/02/18 Policy Expiration Date: 01/11/20
INFORMATION PAGE (Continued) Policy Number: 76 WEG 1O8418
3. A. Workers Compensation Insurance: Part one of the policy applies to the Workers Compensation Law of the states
listed here: CO
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A.
The limits of our liability under Part Two are:
Bodily injury by Accident $1,000,000 each accident
Bodily injury by Disease $1,000,000 policy limit
Bodily injury by Disease $1,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any , listed here:
ALL STATES EXCEPT NORTH DAKOTA, OHIO, WASHINGTON, WYOMING, U.S.TERRITORIES AND STATES
DESIGNATED IN ITEM 3.A. OF THE INFORMATION PAGE.
D. This policy includes these endorsements and schedule:
SEE ENDORSEMENT -WC 99 03 68
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All information required below is subject to verification and change by audit.
Classifications
Code Number and
Description
Premium Basis
Total Estimated Rates Per Estimated
Annual $100 of Annual
Remuneration Remuneration Premium
Total Standard Premium
Premium Discount
Expense Constant
Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement
Catastrophe (Other Than Certified Acts Of Terrorism)
Estimated Annual Premium (before Surcharges)
*See the attached Schedule(s) of Operations for Location and State Level Premium Information
$7,353
-$81
$160
$110
$220
$7,762
Total Estimated Annual Premium:
Deposit Premium:
Policy Minimum Premium:
$7,762
$326 CO (Includes Increased Limit Min. Prem.)
Interstate/Intrastate Identification Number: Refer to Schedule of Operations
NAICS: 621399
Labor Contractors Policy Number: SIC:
Form WC 00 00 01 A (1) Printed in U.S.A. Page 2
Process Date: 12/02/18 Policy Expiration Date: 01/11/20
EXHIBIT C
SCOPE OF SERVICES
1. Contractor will provide Medication Management Services and Mental Health Services, as referred by the
Department.
2. Under this agreement, Contractor will offer the following services:
a. Mental Health Services
i. Individual Therapy
ii. Couples
iii. Family Therapy
iv. Group Therapy
v. Assessments
1. Diagnostic psychological assessment
2. Learning Disability assessments
3. Substance use disorder assessment
vi. Neuro-psychological Testing/Evaluations
1. Administration of psychological evaluations/testing
2. Interpretation of psychological evaluations/testing
b. Medication Management Services
i. Initial medication evaluations
ii. Ongoing medication management services
3. Capacity for Services: Monday through Friday, 7:30 a.m. to 8:00 p.m. Contractor does not offer some
weekend availability on Saturdays.
4. Goals of Service:
a. Help individuals recover from mental health and substance use disorder issues.
b. Offer clients therapy that meets their needs to help them recover and heal from trauma.
c. Immediate availability with 90% of clients scheduled within one (1) week.
5. Outcomes of Service:
a. Provide excellent mental health and substance use disorder treatment.
b. Clients offered an initial appointment with seven (7) days.
c. Offer up to four (4) appointments within 45 days of the first appointment, resulting in weekly
sessions for clients.
d. Ongoing clinical supervision and consultation for all our therapists.
6. Target Population:
a. Young children
b. Adolescents
c. Adults (young, middle-aged and elderly, as well as couples)
d. Families
7. Service Access:
a. Greeley
i. 1770 25th Avenue, Suite 206
ii. 1770 25th Avenue, Suite 202
iii. 1013 37th Avenue Court, Suite 101
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b. Loveland
i. 1032 North Lincoln Avenue
ii. 1413 West 29th Street
iii. 323 East 27th Street
c. Fort Collins
i. 320 West Olive Street
ii. 1525 Riverside Avenue
iii. 1531 Riverside Avenue
iv. 1537 Riverside Avenue
d. Littleton
i. 5911 South Middlefield Road, Suite 100
ii. 5911 South Middlefield Road, Suite 200
e. Denver
i. 950 East Harvard Avenue, Suite 670
f. Castle Rock
i. 410 South Wilcox Street
g. Tele-therapy and medication management available through secure video conferencing.
8. Language: English and Spanish.
9. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-
6210) within three (3) business days regarding the ability to accept the received referral.
10. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of
receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the
referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred
services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral
period, the Contractor will notify the caseworker and the Quality Assurance Team Supervisor
(hainleid@weldgov.com, 970-400-6210).
11. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated
absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate
Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor
understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part
of the client per month. After three (3) "no-shows, "Contractor will place client on a behavioral plan
requiring attendance or discharged client from services. Contractor must inform the caseworker and the
Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210).
12. Contractor understands that the Department will not reimburse Contractor for cancelled appointments
either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a
"makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client
(excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the
Contractor must request a makeup session from the Department prior to the makeup session occurring
(excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the
caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com) immediately via email,
to discuss service continuation.
13. Contractor will identify in detail areas of continued concern and make recommendations to the
Department regarding continuation of services and/or the need for additional services.
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14. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom
the Contractor is working with under an active referral. Areas of concern may include, but are not limited
to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported
immediately AND on the required monthly report.
15. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports
will be submitted per the online format required by the Department, unless otherwise directed by the
Department.
16. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare
Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team
Meeting (FTM), or by court order. A change is defined as anything outside of the approved documented
service on the initial authorized referral form. This may include an increase or decrease in services hours,
change in frequency, change in location of services, transportation needs, or any change to the initial
referral or subsequent authorizations.
17. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings
include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making
meetings. Contractor may participate by phone, if approved by the Department.
18. Contractor will notify the Quality Assurance Team Supervisor (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.
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EXHIBIT D
RATE SCHEDULE
1. Funding and Method of Payment
The Department agrees to reimburse the Contractor in consideration of the work and services performed
under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the
Contractor during the term of this Agreement shall be reported by the Department after May 31, 2020.
Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department
expenditures and shall not be reimbursed by the Department.
Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the
continuing availability of said funds for the purposes hereof. In the event that said funds, or any part
thereof, become unavailable as determined by the Department, the Department may immediately
terminate the Agreement or amend it accordingly.
2. Fees for Services
Medication Management:
$65.00/15 min (Medication Management)
$150.00/Episode (Medication Management Evaluation)
$95.00/30 min (Medication Management, discount)
Mental Health Services:
$95.00/Hour (Assessment)
$120.00/Hour (Neuropsychological Evaluation)
$85.00/Hour (Outpatient Psychotherapy, Master's Level)
$93.00/Hour (Outpatient Psychotherapy, Ph.D. Level)
3. Submittal of Vouchers
Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form,
other supporting documentation, and monthly report if applicable, certifying that services authorized
were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions
of Paragraph 3 and Exhibit A.
Contractor shall submit all Requests for Reimbursement and supporting documentation to the
Department by the 7th day of the month following the month of service, but no later than 60 days from
the date of service. Requests for Reimbursement and/or supporting documentation received after 60
days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the
60 -day deadline may result in termination of the Agreement.
For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client
and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement.
For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the
completed product.
For Monitored Sobriety services, proof of services rendered shall be the test result.
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