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Home My WebLink About20163842.tiffRESOLUTION RE: APPROVE AGREEMENT FOR CHILD PROTECTION SERVICES AND AUTHORIZE CHAIR TO SIGN - JESSICA BRIEN, LPC WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Agreement for Child Protection Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Jessica Brien, LPC, commencing October 21, 2016, and ending June 30, 2017, with further terms and conditions being as stated in said agreement, and WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Agreement for Child Protection Services between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Jessica Brien, LPC, be and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 28th day of December, A.D., 2016, nunc pro tunc October 21, 2016. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: ditiL) o•� Weld County Clerk to the Board BY: o my Attorney Mike Freeman, Chair Sean P. Conway, Pro-Tem te 0.2 ►`uiie A. ozad Steve Moreno Date of signature: Otls,`t! 1 CC. t HS(cmISS/SG) oi/ Iq�I-7 2016-3842 HR0087 'D fly CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND JESSICA BRIEN, LPC This Agreement, made and entered into th day of SP, , 2016 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department' and Jessica Brien, LPC, hereinafter referred to as the "Contractor". r The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Contractor's Proposal, Exhibit B, Scope of Services, and Exhibit C, Payment Schedule. Each of these documents is attached hereto and incorporated herein by this reference. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Child Welfare Administration funding to the Department for Home Studies. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on October 21, 2016, upon proper execution of this Agreement and shall expire June 30, 2017 unless sooner terminated as provided herein. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit B, 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 Department's Resource Manager, Child Welfare Contract and Services Coordinator, or through a Team Decision Making (TDM) meeting or Family Team Meeting (FTM). No other Department staff or other party to the case may authorize services or modifications to services. 1 2016-3842 c. Contractor agrees to submit an itemized complete billing statement by the 7th of the month, following the month of service, utilizing billing forms required by the Department. d. Contractor agrees to submit a monthly report with the billing statement by the 7th of the month following the month of service for each client receiving ongoing services. One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation). Verification of Monitored Sobriety Services will be the test result. 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. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. 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. b. Payment shall be made in accordance with Exhibit A, Contractor's Proposal, Exhibit B, Scope of Services, and Exhibit C, Payment Schedule, attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent upon, the continuing availability of said funds for the purposes hereof. d. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 5. Financial Management 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 0MG Circular A-133. 2 6. Payment Method Unless otherwise provided in Exhibit A, Contractor's Proposal, Exhibit B, Scope of Services , and Exhibit C, Payment 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 ACH Form for Colorado Providers, which will be provided by the Department. Contractor is solely responsible to submit the ACH Form to the State of Colorado per the directions on the form. Failure to complete and submit this form 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 - the Age Discrimination in Employment Act of 1967; and - the Equal Pay Act of 1963; and 3 - 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.5.) 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 Child Welfare Administration. 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. 4 e. Contractor certifies that it shall comply with the provision of the Colorado Revised Statutes (C.R.S.) 8- 17.5-101, et. seq. 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 to the Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor represents, warrants, and agrees that it (a) has verified that it does not employ any illegal aliens, through participation in the Basic Pilot Employment Verification Program administered by the Social Security Administration and Department of Homeland Security, and (b) otherwise will comply with the requirements of C.R.S. 8-17.5-102(2)(b). Contractor shall comply with all reasonable requires made in the course of an investigation under C.R.S. 8-17.5-102 by the Colorado Department of Labor and Employment. If Contractors fails to comply with any requirement of this provision or C.R.S. 8-17.5-101 et. seq., the Department may terminate this Agreement for breach and Contractor shall be liable for actual and consequential damages to the Department. 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 this Agreement, 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 this Agreement. If Contractor operates as a sole proprietor, it hereby affirms under penalty of perjury that s/he (a) is a citizen of the United States or is otherwise lawfully present in the United State 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 this Agreement. 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. 9. Insurance Requirements Contractor and Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. 5 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/Contract Professionals 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/Contract Professionals shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, during any warranty period, and for three (3) years after termination of the Agreement. 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, County must be notified by the Contractor/Contract Professional. Contractor/Contract Professional shall be responsible for the payment of any deductible or self -insured retention. County reserves the right to require Contractor/Contract Professional to provide a bond, at no cost to County, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional shall obtain, and maintain at all times during the term of any Agreement, insurance in the following kinds and amounts: Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance covering all of Contractor's Contract Professional's employees acting within the course and scope of their employment. If Contractor is an Independent Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. ii. Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93 or equivalent, covering premises operations, fire damage, independent Contractors, products and completed operations, blanket contractual liability, personal injury, and advertising liability with minimum limits as follows: - $1,000,000 each occurrence; - $2,000,000 general aggregate; - $50,000 any one fire; and - $500,000 errors and omissions. iii. Automobile Liability: Contractor/Contract Professional shall maintain limits of 6 $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 reduce by twenty-five percent (25%) or more by paid or reserved claims, Contractor shall notify County 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 County. 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 County, whichever is earlier. C. Contractors/Contract Professionals 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/Contract Professional shall provide a copy of this information to its insurance agent or broker, and shall have its agent or broker provide proof of Contractor/Contract Professional's required insurance. County reserves the right to require Contractor/Contract Professional 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/Contract Professional's insurer shall name County as an additional insured as follows f. Waiver of Subrogation: For all coverages, Contractor/Contract Professional's insurer shall waive subrogation rights against County. g. Subcontractors: All subcontractors, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional agrees to provide proof of insurance for all such subcontractors, independent contractors, sub -vendors suppliers or other entities upon request by the County. A provider of Professional Services (as defined in the Bid or RFP) shall provide the following coverage: 7 Professional Liability: Contract Professional 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 that 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 970-352-1551, x6503, 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 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. As the monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures. 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. 8 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: Heather Walker, Administrator 17. Notice For Contractor: Jessica Brien, LPC 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 1970)352-1551 18. Litigation For Contractor: Jessica Brien, LPC 138 East 4`—h Street Loveland, CO 80537 1970)203-4743 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. 9 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 18. 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 10 opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the two relationships are in opposition. During the term of the Agreement, Contractor shall not enter into any third party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. 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. 11 Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contractor agrees it is an independent contractor and that its officers and employees do not become employees of Weld County, nor are they entitled to any employee benefits as Weld County employees, as the result of this Agreement. 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, and C. 12 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to Department originals of all tests and results, reports, etc., generated during completion of this work. Acceptance by 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 conflict 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 Contract Professional'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, Contract Professional agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 13 35. Attorneys Fees/Legal Costs In the event of a dispute between County and Contract Professional, 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. 14 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: WZ 4 BOARD OF COUNTY COMMISSIONERS Weld Cooraty Clerk to the Board WELD COUNTY, COLORADO By: Deputy Clerk to t 4/1 15 Mike Freeman, Chair CONTRACTOR; Jessica Brien, LPC 138 East 4th Street Loveland, CO 80537 (970) 203-4743 By: Date: DEC 2 & ZC:- Jesssica Brien, LPC OZo/6,- EXHIBIT A CONTRACTORS PROPOSAL Jessica Brien, MA, LPC 138 East 4th Street Loveland, CO 80537 September 7, 2016 Attention: Tobi Vetger Child Welfare Contract and Services Coordinator Weld County Department of Human Services I am interested in performing SAFE home studies for Weld County. My SAFE training certificate is attached. I have six years of experience performing a variety of SAFE home studies and also worked in a child placement agency for seven years. I currently maintain a private therapy practice in Loveland, CO. I have continued to perform home studies as a contractor for my former employer since starting my private practice. I am interested in serving families of all structures who want to provide foster care or adopt a child, as well as kinship families being considered for placement. I have the knowledge, experience and desire to perform all of these types of studies (relative care, foster care, parent care, foster -adopt, adoption, and ICPC). I will accept referrals for families who live in Larimer and Weld counties. My supervisor is Sheila Trabelsi. Her training certificate is attached. She can be reached at sr trabelsi@vahoo.com My rate schedule would be as follows: $1400 for a completed full home study report (approved or denied). This rate includes a minimum of three face to face contacts with the family, the writing of a full home study, and all mileage and associated costs within central Larimer and Weld County. $300 for incomplete home study (denied or family withdrew). This rate includes one to two face to face contacts, writing a brief report documenting reasons for the decision, and all mileage and associated costs within central Larimer and Weld County. $25 per hour travel time for any home more than 10 miles outside of central Larimer and Weld county (Greeley, Fort Collins, and Loveland). Please contact me with any questions or further information your might require from me. I look forward to your response. Sincerely, ssica Brien, MA, LPC jessicakbrien@qmail.com (970) 203-4743 Jessica Rude Brien, MA, LPC 138 E. 4'h Street Loveland, CO 80537 Phone: (970) 203-4743 Email: jessicakbrien@gmail.com QUALIFICATIONS: • Six years of experience performing SAFE home studies. • Licensed Professional Counselor with 8 years of experience in a variety of fields, including trauma, attachment, managing challenging behaviors and parenting support. • Skilled in EMDR, play therapy and family therapy. EMPLOYMENT: September 2015 -present Private Practitioner at Jessica Brien, MA, LPC, LLC • Provide individual, family and couples therapy to clients of all ages. • Perform SAFE home studies contracted through Lutheran Family Services. June 2012 -present Lutheran Family Services Rocky Mountains Clinician, Foster Care and Family Services • Provided therapy for children in therapeutic foster care, family therapy and parent education for at risk families, and performed SAFE home studies for a variety of families. • I lelped children adjust, process grief and loss, and form healthy attachments; instructed parents on how to communicate and build healthy relationships. January 2012 -June 2012 Touchstone Health Partners Outpatient therapist, Child and Family Team • Provided intake, crisis intervention, and ongoing therapy services. • Facilitated healthy communication, anger management, and trauma processing groups. May 2008 -December 2011 Lutheran Family Services of Northern Colorado Clinician, Foster Care and Family Services • Provided therapy for children in therapeutic foster care and family therapy and parent education for at risk families. • I ielped children adjust, process grief and loss, and form healthy attachments; instructed parents on how to communicate and build healthy relationships. March 2007 -August 2008 The Greeley Transitional House, Inc. Child and Adolescent Program Coordinator • Met weekly with each child and his or her parents to help with adjustment and access to resources. • Assisted clients through brief clinical interventions and crisis management as needed. EDUCATION: August 2006- December 2008 Master of Arts Degree, University of Northern Colorado Clinical Counseling with an emphasis in Couples and Family Therapy August 2002 -May 2006 Bachelor of Arts Degree, University of Northern Colorado Psychology Certificate of Insurance (Proof of Coveragel Date Issued: (8/2/20161 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Insured Name and Mailing Address* Program Administrator Name Jessica Brien Street 602 Denali Ct. City Windsor State Colorado Zip 80550 Administered By: CPH and Associates 711 S. Dearborn, Suite 205 Chicago, IL 60605 P. 312-987-9823 F. 312-987-0902 info@cphins.com Underwritten By: Philadelphia Indemnity Insurance Company *Additional insured locations are often requested by individual business owners who have more than one office. Your coverageis portable, meaning that you are covered at any location for practice under the occupation(s) listed on your policy. Coverage Policy #: E241641 (Effective Date: (8/2/2016) (Expiration Date: (8/2/2017) POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH IS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, T"MIS XCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits of Liability Coverage Part Each Occurrence (Per individual claim) Aggregate (Total amount per policy year) $1,000,000.00 $5,000,000.00 Professional Liability N/A N/A General Liability Includes: General Liability, Fire & Water Legal Liability and Personal Liability N/A N/A Property Coverage $1,000,000.00 $5,000,000.00 Supplemental Liability Unlimited Unlimited Defense Expense Coverage $35,000 $35,000 State Licensing Board Investigation Defense Coverage $15,000 $15,000 Assault Coverage $10,000 $35,000 Deposition Expense Benefit $5,000/person $50,000 Medical Expense Coverage $15,000 $15,000 First Aid Coverage Description/Special Provisions: Certificate Holder Cancellation Weld County DHS PO Box A Greeley, CO 80632 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Holder has also been added to the policy as an additional insured:** XYes / _No **If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ittrits% Authorized Representative C. Philip Hodson DISCLAIMER:Tbe Certificate of Insurance does not constitute a contract between the Issuing insurer(s), authorized representative or producer, and the certificate holder, nor does It affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon. c&yet,fif,e,a,t,e ktion SAFE FOR SUPERVISORS - Structured Analysis Family Evaluation This is to certify that Sheila Trabelsi has completed 6 hours oESSFE Training and Is certified to supervise SAFE Home Studies Due(s) Oli ddeen CkaiT. Etauuve Divan CeaseNem for CAl&&m I ti sks V I a re v O • SAFE Home Study LUTHERAN FAMILY SERVICES Roc Mountains Home study was completed by: Jessica Brien MA, LPC 138 E. 4th Street Loveland, CO 80537 Name of Family Family Address Family Home Phone. >> APPLICANT DISPOSITION Application received on: 3/14/16 Home study completed on: 8/11/16 ►5 FUTURE PLACEMENT of a male or female child between the ages of 14 and group. If open to a sibling group, The Applicants applied to become a Foster Family placement 18. The Applicants are not open to the placement of a sibling how many? ❑ CHILD SPECIFIC PLACEMENT The Applicants applied to become Select One for Name(s), birthdate(s). >> APPLICANT INFORMATION Illigla Maiden Name (if applicable): n/a Maiden Name (if applicable): n/a Date of Bir Date of flirt Mobile Phone Mobile Phone Work Phone: none Work Phone: none E -Mail Addres E -Mail Address Birthplace. Birthplace Sex: Male Sex: Female Height: 5' 10" Height: 5' 3" Weight: 165 lbs. _ Weight: 135 lbs. Hair: Brown Hair: Blond Eye Color: Brown Eye Color: Blue Religion: none Religion: none Education: PhD Educatiou: PhD Language(s): English, some French Language(s): English, some French Consortium for Children, ®2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V0'7-01.2015 1 SAFE Home Study Lives in Firestone, Colorado. >> REFERENCES Name Relationship to Applicants Date Received Friend/boss a 6/20/16 Friend o 6/16/16 Friend o 6/16/16 Friend/roommate call 6/20/16 » MEDICAL/SCHOOL REPORTS Medical Reports Health Evaluation from pertaining to completed on: 7/27/16 >> APPLICANT'S/OTHER'S CRIMINAL/CPS RECORDS CHECK The required criminal record and child abuse/neglect checks (including Trails and all the States the Applicants or other adults livin in the home have resided in for the past 5 years) were completed fo an ong with any adult(s) living in the Applicants' home. Any rem ar e o other findings wil a ela orated on in the History or Sons/Daughters/Others Residing or Frequently in the Home Section of the Psychosocial Evaluation. 1110. CBI Criminal Records Check 5/26/16 FBI Criminal Records Check 5/31/16 Colorado Court Access 6/6/16 Trails/Other States' Child Abuse/Neglect Checks for 5 Years 6/2/16 DMV 5/27/16 Local Law Enforcement 6/3/16 National Sex Offender Registry 6/8/16 CBI Criminal Records Check 5/26/16 FBI Criminal Records Check 5/31/16 Colorado Court Access 6/6/16 Trails/Other States' Child Abuse/Neglect Checks for 5 Years 6/2/16 DMV 5/29/16 Local Law Enforcement 6/3/16 National Sex Offender Registry 6/8/16 Consortium for Children, ©2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 3 SAFE Home Study The couple split bill paying, which is automated. They pay for professionals to do house maintenance and to clean once a month. Both do picking up around the house, an does any deep cleaning needed between professional cleanings. The dogs are a shared responsibi i oes the cooking and food shopping, anal does yard work, trash and recycling. Their family rules will be modified based on the child placed with them, but are generally as follows: 1. No smoking, drugs, alcohol or weapons. 2. Be kind to the dogs. Remember to turn off the heat downstairs (downstairs is on a different thermostat and gets too hot for dogs during the day) and don't let them out the front door. 3. No racist, sexist or homophobic language. 4. Clean up after yourself and wash your laundry and sheets once a week. 5. Change clothes only in your mom or bathroom with the door closed. 6. Don't ente offices without asking. 7. No hitting, s g or ying. S. When you leave the house, let_know where you are going and when you will be back. 9. Quiet after 11pm. 10. No guests without permission from 11. Wear a helmet when riding your bike. The don't participate in organized religion with any regularity. amily has Jewish heritage an sothey will celebrate some Jewish holidays with friends or family in a sera ar way. family is Christian and celebrate Christian holidays. The couple enjoy celebrating Thanksgiving and Christ with friends. They will see their parents for Father's and Mother's Day. They are open to supporting a youth's cultural and religious background. The couple has two dogs, They share caretaking responsibility for the dogs. The dogs are both comfortable around children. CHILD CARE The ould like to provide a home for an older teen who could be alone for a few hours at a time an o no anticipa needing childcare with their flexible schedules. They do have a variety of friends and family who live nearby who are willing to help out if they do need care for longer than a few hours or in an emergency arises. If they needed to travel or be away for longer periods of time they would arrange for respite care. PRIVACY slee in a bedroom upstairs and a child placed in the home would sleep in a bedroom in the asement. have their own bathroom and a child would have their own bathroom as well. Nudity in the home would only be permitted in the bedroom or bathroom with doors closed. >> LEGAL/FINANCIAL RESPONSIBILITIES Thhave been advised of their duty of honest disclosure along with their ongoing duty of reporting new events or information that may require an updated or amended home study. Th derstand that should they file a petition to adopt, they will be accepting full legal and financial responsibility once the adoption is finalized. Consortium for Children, O2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 5 SAFE Home Study PSYCHOSOCIAL EVALUATION REPORT >> HISTORY: was born in Bloomington, Indiana. He was the only child born to his parents. He attended elementary and ml a school in Indiana. His family then moved to New Terse and he attended high school and college there' then moved to California to attend graduate school. He me there and they married in 2009. The couple moved to Colorado foi[o complete a post -doctorate program at Colorado State University (CSUIIII is an adjunct professor at CS1THis father died seven years ago and his mother now lives in London, Englan EVALUATION Growing up,family was ready, willing and able to accept differences respectfully and communication was respectful an we -received. grew up in a stable, intact family and his emotional and developmental needs were well met. He was never p ysically, sexually or psychologically abused as a child. He has never been suspected of, investigated for or convicted of any form of child abuse or neglect._has no history of arrests or convictions, has never been diagnosed with a psychiatric condition, and has a history of stable full-time employment. He has no previous marriages or domestic partnerships. Of moderate concernahas experimented with some illegal drugs. He tried mescaline a few times, marijuana twice, and GHB a fev=silecurrently drinks one or two alcoholic drinks a week and does not use any illegal drugs use of mescaline and GHB was over 15 years ago, and his most recent marijuana use was several years Se did not enjoy the effects of any of the drugs. He has no plans to use illegal drugs or marijuana in the future. This does not appear to be a concern that would affect the placement of children in the home. Of minimal concernlireIt some emotional distance from his parents growing up. His mother was anxious and perfectionistic and hisr was rigid and critical. parents were also loving and caring. He has positive memories of travelling with his family and enjoyeefig.rmg sports with his father. He relied on his friends for emotional support growin and developed numerous positive and supportive friendships of the years, some of which he maintains today. understands the need to balance warmth and control in parenting. Also concerning, father died when he was an adult. This was a sad time for He slept less following this as he grieved. Over time, the sadness over this has faded but he continues to miss his a er. It appears_tas grieved this loss in a healthy manner. Additionally,i grandparents died while he was an adult, close to the time his father died. He was not close to his grandparents and grieved their deaths appropriately. is had one surgery as an adolescent where his jaw had to be wired shut. He remembers this being uncomfortable an eird, but not upsetting. He recovered fully from this and suffers no further issues from this today. father spanked him a few times as a child. This was not done in anger and was not traumatic foal He oes not plan to use spanking to discipline youth in his care. » PERSONAL CHARACTERISTICS: takes the following medications: mitriptyline 10mg daily for acid reflux. Gabapentin for nerve pain. EVALUATION asis a clear communicator and there is congruence between his verbal and nonverbal communication. He has a good sense of personal responsibility and cooperation and is able to deal with conflicts and resolve disagreements. He maintains several close and enduring adult relationships and is able to form a realistic assessment of his strengths and limitations.- has a good understanding of the varying world views, values and belief systems of others. He is able to cope successfully with the stresses of everyday life and is able to delay gratification of wants/needs when necessary. His mood is typically optimistic and relaxed and he rarely experiences intense, angry Consortium for Children, O2013 all rights reserved-Snvctwed Analysis Family Evaluation, Colorado V07-01-2015 6 SAFE Home Study feelings.- is able to make a decision or form an opinion objectively and wisely, and he is flexible and open to new experiences, ideas and relationships. Of minimal concern has some chronic health conditio He has arthritis in his neck which causes him pain. This pain sometimes makes it difficult for him to sleep. pain has been managed fairly well with the current medication he is on. He regularly visits his doctor and a p ysical therapist to help ease the paint. health conditions are well managed and only cause him minimal stress. They do not appear to be a concern for the placement of youth in the home. >> HISTORY as born in St. Louis Park, MN and moved to Boulder, Colorado when she was very young, which is where s e was raised. She was the only child born to her parents. Her parents divorced when she was five. She attended school until high school graduation in Colorado and then moved to Connecticut to attend college. After college she moved to California to attend graduate school. She me there and they married in 2009. The couple moved to Colorado foo complete a post -doctorate position at olorado State University (CSU)norks for a national wil t e conservation association which is housed at CSU. EVALUATION Growing up family was readily able to make necessary adjustments to accommodate new circumstances and relations ps. She did not experience any physical or sexual abuse as a child. She has never been suspected of, investigated for or convicted of any form of child abuse or neglecas had a successful and fulfilling occupational career. She has no previous marriages or domestic p ers ps. Of serious concern, both olparents have major psychiatric conditions. Her mother is an alcoholic and durin childhood or vanous suicide threats and attempted suicide one time, which witnessed. Her mother ve her car off a cliff into a stream r left the car minutes before this happened. Her father has bipolar disorder which was untreated until recen y d not spend much time with him as a child, but did visit him. Her father attempted suicide wheawas an . • u . Both parents have suffered from these conditions since ��as a child. A select few extender amr y members also suffer from mental illness an? experienced depression and anxiety off and on for a few years in the past. Related to this concern,_- enced a chaotic upbringing, with low parental involvement due to her mother's addiction and mental r ess. also witnessed domestic violence between her stepfather and mother and was emotionally abused by her ster, who would yell at her and shame hera spent time out of her home twice growing up. The first time her mother went to a rehab facility and she staye wt her aunt. Later as a teen she chose to leave to stay with a friend to get away from the dysfunctional dynamics in mother's home. gia was fortunate to have a healthy and supportive network of friends and extended family of several aunts annsins who filled in for her parents while she was growing up and provided her a strong and healthy foundation and the experience of a healthy family also excelled at school and took solace and great pride in succeeding there. She participated in counseling as a child and also for a few ears as an adult to help her work through the emotional and psychological impact of these events. Today, retains strong relationships with her aunts. She is cordial with her parents but does not enjoy time with them an limits her contact with them. When she does see them it is a very surface level interaction' demonstrates many resiliency factors which enabled her to rise from a potentially damaging situation into the successful, confident, happy person she is today. past experiences do not appear to be a factor that would negatively impact the placement of children in the ome, but rather to be an asset that will allow her to be more understanding of youth in similar situations. Of moderate concern, has used illegal drugs in the past. She has used marijuana and Ecstasy a few times each...felt these gs either made her paranoid or had no effect. Currently, Prinks one to two drinks once or twice a week and does not use any other drugs. As this drug usage happen in the past and is not somethings interested in continuing this does not appear to be a concern that would negatively effect the placement o children in the home. Consortium for Children, ©2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 7 SAFE Home Study Of minimal concern,sxperienced a few traumatic events as an adult. In college she chose to have an abortion. She was not rea to have a child and feels this was the best choice for her. At the time she was sad, but feels no regret today. !so saw a dead body when she lived in the Bay Area of CA. The person had recently been murdered and this was shocking and scary to her. This was an impetus for to make their move to CO as they were already not feeling safe. The couple purchased a dog for prote as careful to not go running alone following this, which allowed her to feel safe until they could move also lost her grandparents as an adult. vas not extremely close to her grandparents and griev eir losses appropriately. Also minimally concerning was arrested in 1999 for a civil obedience protest in CT. She was part of a demonstration for labor righ an everyone in the protest was arrested for blocking the doorway to a building. This was a nonviolent protest for a cause_ believed in and does not indicate a violent or nonconformist nature. >> PERSONAL CHARACTERISTICS: is not taking any medications currently. She is prescribed an albuterol inhaler to use as needed but has not nee ed to use it for a while. EVALUATION ccoun�s a clear written and verbal communicator and is dependable and demonstrates appropriate personal tability. She is proactive, problem solves in a timely manner, and has a good capacity for empathy and caring in relationships. is in good health and physically active, and has good self-esteem and self-worth. She is sensitive to and respe of the customs, values and belief systems of different cultures has a good ability to cope in highly stressful situations, and is able to control impulsive thoughts, feelings and e a iors. Her mood is engaging, warm and approachable and she rarely experiences intense, angry feelings makes good decisions based on the facts of a situation and is able to deal effectively with a variety of new sr tions. >> MARITAL/CIVIL UNION RELATIONSHIP ave been married since 2009. handles the yard work, trash and recycling an s ote pping and cooking. They share responsibility or their dogs and bill paying duties. more o e social planner and negotiator andel" the homemaker, organizer and emotional one. EVALUATION ere sensitive to each other's needs and are able to express their feelings. They enjoy each other's company and recognize the personal strengths and abilities of the other. Both are good listeners and communicate directly. The couple work cooperatively with each other and power is shared through consensus. Both partners are firmly committed to their relationship and have a high degree of confidence their marriage will endure. They report a mutually satisfying sexual relationship. Of minimal concern, the couple occasionally has difficulty talking through and resolvin conflicts. In particular around what hours they will sleep. would prefer to stay up later and sleep later an' would like to o to sleep earlier and get up earlier. rs a light and sensitive sleeper maki possible or him to sleep' is awake. The debate around when ey will sleep at times feels t e one's needs are being prioritized over the others. The couple has negotiated about this numerous times, and although they come to a place of compromise for a while the issue continues to come up. xplains that with a youth placed with them they will likely need to get up earlier to help the child get ready an= to school, and he does not feel resentful of this. He an ere able to adjust their schedule accordingly for their placement last year and do not anticipate any di icu oing so in the future. This does not appear to be an issue which would negatively impact the placement of the child in the home. Consortium for Children, O2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 8 SAFE Home Study extended family is positive regarding the couple's desire to provide foster care. No one has experience as aster or adoptive parents. EVALUATION enjoys a positive relationship with many members oiS family, many of whom live close and are ready, wtllmg and able to be supportive of a new child or youth coming into the family.- mother and aunts are adaptable and willing to accept differences and embrace new members. Of minimal concern elationship with his mother is stressful. His mother is highly anxious and frustrating and challenging to be around. maintains email contact with his mother and sees her a few times a year, but does not feel a strong sense o connection or warmth towards her, has a well -developed network of friends who he does feel a sense of connection and belonging to. This soot support system is ready, willing and able to provide both tangible and emotional support to the couple. >> EXTENDED FAMILY RELATIONSHIPS: Everyone in family is supportive of the couple's desire to provide foster care for children. One ofr aunts adopted three children, andr lived with her aunt when she was a youth and removed from her mother's care. EVALUATION isenjoys healthy and positive family connections with her aunts and cousins, man of whom live nearby and are ready, willing and able to provide both tangible and emotional support to Her family is readily able to make necessary adjustments to accommodate new circumstances and re ationships. contact with _mother, which is limited, is generally positive. Of minimal concern relationships with her parents are challenging and strained. Her parents have substance abuse and mental health struggles that led t. being placed out of their homes as a child (see history section above for more detail). f aunts and other ex nded family filled the roles her parents were unable to, and consequently is not negatively impacted by the lack of closeness with her parents. o see her parents occasionally and while they do not have any current safety concerns for either of her paren ey would not leave a youth in their care unsupervised around the so has a large support system of friends who function as family to her who are ready, willing and able provide tangible and emotional support. >> PHYSICAL/SOCIAL ENVIRONMENT The couple's gross monthly income is $10 835 and their net monthly income is $8996. This income is reliable and sufficient to meet their needs.e able to budget, organize and spend within their budget. They do not have debts and live within etr mantes. ey have money available in savings and investments that could be used in an emergency. No obvious safety concerns were noted by this ev anal safety inspection will be completed by Lutheran Family Services. The cou le has two dogs,. They are both well cared for and comfortable around children. Neither smokes. EVALUATION ome is clean, comfortable and well maintained. it has adequate furnishings and reliable understand the need to provide proper clothing and age appropriate play/recreation equipment an areas 't outh placed in their care. They have numerous supportive and helpful friends who are willing to offer both tangible and emotional support. >> GENERAL PARENTING Consortium for Children, O2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 9 SAFE Home Study As a child,rwas disciplined strictly with lecturing and grounding. His father spanked him a few times when he was very young (addressed in more detail in history section, above). lirowing up, was rarely disciplined. Her mother would praise positive behaviors and her father would lecture and shame her. Ian to use primarily positive methods to discipline, such as praise and rewarding good behavior. ve in talking with youth about the rules/expectations in advance and explaining the rationale behind them. They have a good understanding of discipline methods and will tailor consequences to the specific youth, primarily planning to remove privileges. EVALUATION The have a good, realistic knowledge base regarding child development. They understand the importance of incorporating both warmth and control in their en ' . A child placed in their care will be well - supervised, with substitute caregivers chosen with care lan to be directly involved in a child's leaning experiences, including advocating for a child at sc oo . They have a realistic confidence in their parenting abilities and are positive and enthusiastic about parenting. Both have a good understanding of child relationship interactions and a good ability to communicate at a child's level of understanding. The grooming, nutritional, safety and medical needs of a child placed in their care will be met. will provide an environment that encourages playfulness and understand the importance of play an or a child's healthy development. » SPECIALIZED PARENTING FAMILY PREPARATION AND TRAINING ACTIVITIES The ttended 2g hours of Parents as Tender Healers (PATH) training through Lutheran Family services. ey were interested in learning more about the neuroscience behind trauma. EVALUATION The couple have realistic expectations about the challenges and rewards of child placement. Both understand how a child's normal emotional and physical development may be impacted by the abuse and/or neglect he or she experienced and have effective strategies for managing many common behaviors associated with child abuse and/or neglect. They have a good understanding of the unique issues that relate to sexual abuse and how to discern normal sexual interest from overly sexualized behavior. have a good understanding of the behavioral effects of separation, multiple foster care placemen and disrupted adoptions and the ability to deal with these behaviors in a therapeutic manner. They have well -established and easily maintained daily routines and consistent are effective consumers of therapeutic and educational resources. They understand the need tobe responsive to appropriate birth sibling and birth parent contact, and to be sensitive and respectful to birth parent's situations. would actively collect information about a child's medical, social and educational backgroun . parental expectations. The » ADOPTION/FOSTER CARE ISSUES The are fully supportive of maintaining birth family connections for a child in foster and/or adoption, r r is m e st interest of the child. They believe adoption is a positive way to form a family and would be secure in their role as adoptive parents. are committed to being involved in visits, team meetings and undertaking other duties as needed to me e a permanency goal of a child. EVALUATION The couple is skilled in discussing adoption and providing an open atmosphere for a child to freely discuss birth parents and life prior to adoption. They are not currently interested in adoption, but would like to consider it down the road. If they do decide to pursue adoption, they will be prepared to make a permanent commitment to the child as a family member. » PSYCHOSOCIAL EVALUATION CONCLUSIONS Consortium for Children, ©2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 10 SAFE Home Study are intelligent, thoughtful and caring individuals with an abundance of interpersonal strengths. They ave a cooperative, committed and enjoyable marriage. They have a safe and clean home, with adequate financial resources. Both have extensive experience with children and teens and have studied and built a strong knowledge base regarding parenting, the effects of abuse and neglect, and how to discuss foster care and adoption issues with children. The couple draws emotional and tangible support from a strong network of friends and_extended family. III raised in a stable, intact family and had little trauma growing up. He has experienced minimal trauma as an a It as well. Today, he has a strained relationship with his mother, but sees her rarely and thus does not experience much stress from this. ad a traumatic, chaotic upbringing with her parents divorcing and both suffering from mental illness.- ed monstrated resiliency by recognizing the unhealthy dynamics and vowing to not be a part of them. She also attended therapy, found sitive ways to succeed such as excelling at academics, and leaned on the support of her aunts growing up. has experienced minimal trauma as an adult. Her relationship with her parents is strained but she continues to ve a warm and supportive relationship with her aunts and cousins, is mindful of the fact that fostering a youth may trigger things from her past. She is self -aware and would see out support through friends and family or counseling as needed if this arises. There are no concerns that cannot be fully mitigated for the amity. » PLACEMENT CONSIDERATIONS FUTURE PLACEMENT CONSIDERATIONS are compatible with a male or female youth from any religious, cultural or ethnic background een the ages of 14 and 21. They are open to legal risk. They are uniquely qualified to accept a youth who shares one of their many interests, such as music, arts and culture, reading, science/school enrichment, various outdoor and active pursuits and dogs. They are prepared to accept a youth with a variety of common behaviors, such as unusual sleeping/eating, irritability/moodiness, and lack of warmth/aloofness. Additionally, they will accept a youth who has special needs related to school, is hyperactive, has food issues, uses profanity or practices self - harm. They are willing to accept a youth with mild medical needs, such as asthma or diabetes, ADD, an eating disorder and depression. The couple is not willing to accept a youth who needs placement with a sibling, needs special physical accommodations that their home is not equipped for, or has moderate to severe medical needs, such as cerebral palsy or fetal alcohol spectrum disorder. They are also not prepared to accept a youth who demonstrates sexualized behaviors, smears stool, is physically aggressive, sets fires or is cruel to animals >> RECOMMENDATION It is recommended that elabe approved for Foster Care Placement and Adoption. Home Study Evaluator: I affirm that I conducted this home study in accordance with Colorado law and the rules adopted by the Colorado Department of Human Services. This home study was conducted with due professional diligence that is reasonably necessary to protect the best interests of any child whom the Applicants might adopt or foster as a result of this home study. The factual statements in the home study are true and correct to the best of my knowledge and information received. Supervisor/Agency Designee: I concur with the above recommendation and verify that this home study was conducted with due professional diligence and in accordance Colorado law and the rules adopted by the Colorado Department of Human Services. Date: (Signature) Placement Supervisor Consortium for Children, O2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01.2015 II SAFE Rome Study I am authorized by Colorado law and the rules adopted by the Colorado Department of Human Services to conduct home studies and do so by virtue of my status or employment with: County Department of Human/Social Services Child Placement Agency Contractor Approved by Lutheran Family Services Rocky Mountains Approving Agency Authority (if applicable): I am authorized by Colorado law and the rules adopted by the Colorado Department of Human Services to approve families for adoption and foster care. Based on my review of this home study report and the recommendation cited above, the Applicants are for . Signature J Date Signature Date Jessica Brien, MA, LPC Name of Authorized Approving Authority Contractor Title >' APPLICANTS' REVIEW OF HOME STUDY REPORT By signing below, I acknowledge that I have read a copy of this home study and affirm that the information I provided for this report is true and correct to the best of my knowledge. Signature Date Signature Date Check for document updates Consortium for Children, O2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 12 SAFE Home Study PSYCHOSOCIAL INVENTORY RESULTS #1 i #2 I Applicant #1. #1 EXTENDED #2 Applicant #2: FAMILY RELATIONSHIPS HISTORY 3/2 2 Extended Family Cohesion 2 2 Childhood Family Adaptability 2 2 Extended Family Adaptability 3/2 4/2 Childhood Family Cohesion 3/2 3/2 Relationship with Own Extended Family 2 4/2 Childhood History of Deprivation/Trauma 2 2 Relationship with Spouse/Partner Family 3/2 2 Childhood History of Victimization PHYSICAL/SOCIAL ENVIRONMENT 3/2 4/2 Adult History of Victimization/Trauma 2 Cleanliness/Orderliness/Maintenance 2 2 History of Child Abuse/Neglect 2 Safety 4/2 4/2 History of Alcohol/Drug Use 2 Furnishings 2 3/2 Crime/Arrest/Allegations/Violence 2 Play Area/Equipment/Clothing 2 5/2 Psychiatric History 2 Finances 2 2 Occupational History 2 Support System N/A N/A Marriage/Domestic Partner History 2 Household Pets PERSONAL CHARACTERISTICS GENERAL PARENTING 2 2 Communication 2 2 Commitment and Responsibility 2 2 Child Development 2 2 Parenting Style 2 2 Problem Solving 2 2 Disciplinary Methods 2 2 Interpersonal Relations 2 2 Child Supervision 3/2 2 Health and Physical Stamina 2 2 Learning Experiences 2 2 Self-esteem 2 2 Parental Role 2 2 Acceptance of Differences 2 2 Child Interactions 2 2 Coping Skills 2 2 Communication with Child 2 2 Impulse Control 2 2 Basic Care 2 2 Mood 2 2 Child's Play 2 2 Anger Management and Resolution SPECIALIZED PARENTING 2 2 Judgment 2 2 Expectations 2 2 Adaptability 2 2 Effects of Abuse/Neglect MARITAL/DOMESTIC PARTNER RELATIONSHIP 2 2 Effects of Sexual Abuse 3/2 Conflict Resolution 2 2 Effects of Separation and Loss 2 Emotional Support 2 2 Structure 2 Attitude toward Spouse 2 2 Therapeutic/Educational Resources 2 Communication between Couple 2 2 Birth Sibling Relationships 2 Balance of Power 2 2 Child Background Information 2 Stability of the Marriage 2 2 Birth Parent Issues 2 Sexual Compatibility ADOPTION/FOSTER CARE ISSUES SONS/DAUGHTERS/OTHERS RESIDING OR I FREQUENTLY IN THE HOME N/A N/A Infertility N/A Minor Sons and Daughters 2 2 Telling Child about Adoption N/A Minors Residing or Frequently in the Home 2 2 Openness in Adoption N/A Adult Sons and Daughters 2 2 Adoptive Parent Status N/A Adults Residing or Frequently in the Home I affirm that each psychosocial factor listed above was considered and rated with due professional diligence on the SAFE Psychosocial Inventory during the course of this home study. The ratings above represent the Final Desk Guide Ratings and corresponding Mitigation Ratings for all Final Desk Guide Ratings of 3, 4 or 5. Signature Date Signature Date Jessica Brien, MA, LPC Contractor acement Supervisor Consortium for Children, O2013 all rights reserved -Structured Analysis Family Evaluation, Colorado V07-01-2015 I3 EXHIBIT B SCOPE OF SERVICES 1. Contractor will provide home study services for Weld County families, as referred by the Department. 2. All services will be provided by Jessica Brien, LPC. 3. Contractor will utilize the Structured Analysis Family Evaluation (SAFE) tool developed by the Consortium of Children. Contractor is SAFE certified and on the State's approved home study vendor list. Contractor also is under the supervision of SAFE Supervisor, Sheila Trabelsi. 4. Contractor will attend SAFE Refresher training during the term of this contract. 5. Contractor will ensure that all studies are completed utilizing the most up-to-date forms and templates as found on www.consortforkids.org or www.SAFEhomestudy.org. 6. Contractor will complete a Department of Motor Vehicle background check at no additional charge. All CBI, FBI and LexisNexis background check information will be completed by the Department, unless otherwise directed by the Department. 7. Contractor will submit a completed home study to the Department with their billing within 60 days of receipt of the home study referral. A complete home study will include the study in SAFE format, background check information, SAFE questionnaires completed by the applicants, references and all other original documents submitted by the home study applicant. 8. Contractor will document in detail any and all observed or verbalized concerns regarding any specific Weld County home. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Child abuse must be reported immediately per law. 9. Contractor will make at least three (3) attempts to contact the client and set up services. The first attempt will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If after three (3) attempts the client does not respond the Contractor will notify the referring caseworker and the Child Welfare Contract and Services Coordinator immediately. 1 EXHIBIT C PAYMENT 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 specified 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, 2017. 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 $1,400.00/Episode (Home Study, up to 2 Adults) $500.00/Episode (Home Study Update, up to 2 Adults) $50.00/Episode/Per Person (Additional fee per adult after 2 adults) $300.00/Episode (Partial home study; denied or withdrawn after 1-2 face-to-face contacts. Includes brief written report and all mileage costs within central Larimer and Weld County, include Greeley, Loveland, Fort Collins and communities located between those three.) $ .54/Mile (After 10 miles outside central Larimer or Weld County. Communities included at no mileage charge include Greeley, Loveland, Fort Collins and communities located between those three. Mileage starts at the outer city limit of each.) Contractor may not attempt to collect co -pays and/or fees for services for which a Department client is responsible, but which a particular client refuses or fails to pay. Contractor will collect any applicable sliding scale co -pays and credit the Department for any payment received on the monthly billing. 3. Submittal of Vouchers Contractor shall prepare and submit monthly an itemized voucher, and signed monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges made were pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all monthly billings and applicable reports to the Department by the 7th day of the month following the month the cost was incurred. Failure to submit by the aforementioned deadline may result in forfeiture of payment. 1 a. 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. b. For one-time services, proof of services rendered shall be receipt of the completed product. c. For Monitored Sobriety services, proof of services rendered shall be the test result. Certificate of Insurance (Proof of Coverage) Date Issued: (8/2/2016) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Insured Name and Mailing Address* Program Administrator Name Jessica Brien Street 602 Denali Ct. City Windsor State Colorado Zip 80550 Administered By: CPU and Associates 711 S. Dearborn, Suite 205 Chicago, IL 60605 P. 312-987-9823 F. 312-987-0902 info@cphins.com Underwritten By: Philadelphia Indemnity Insurance Company *Additional insured locations are often requested by individual Your coverageis portable, meaning that you are covered at any location business owners who have more than one office. for practice under the occupation(s) listed on your policy. Coverage Policy #: E241641 'Effective Date: (8/2/2016) 'Expiration Date: (8/2/2017) THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN NAMED ABOVE FOR THE POLICY PERIOD INDICATED. OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits of Liability Coverage Part Each Occurrence (Per individual claim) Aggregate (Total amount per policy year) $1,000,000.00 $5,000,000.00 Professional Liability N/A N/A General Liability Includes: General Liability, Fire & Water Legal Liability and Persoeal Liability N/A N/A Property Coverage $1,000,000.00 $5,000,000.00 Supplemental Liability Unlimited Unlimited Defense Expense Coverage $35,000 $35,000 State Licensing Board Investigation Defense Coverage $15,000 $15,000 Assault Coverage $10,000 $35,000 Deposition Expense Benefit $5,000/person $50,000 Medical Expense Coverage $15,000 $15,000 First Aid Coverage Description/Special Provisions: Certificate Holder Cancellation Weld County DHS PO Box A Greeley, CO 80632 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Holder has also been added to the policy as an additional insured:** XYes / No **If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). IYyfJKf JrJ} /440.‘ s Authorized Representative C. Philip Hodson DISCLAIMER:The Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does It affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon. Hello