HomeMy WebLinkAbout20161941.tiffCONTRACT AGREEMENT AMENDMENT BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND BARRY R. LINDSTROM, PH.D., LLC (Core)
This Agreement Amendment, made and entered into °OS day o 2016, by and between
the Board of Weld County Commissioners, on behalf of the Weld Count epartment of Human
Services, hereinafter referred to as the "Department", and Barry R. Lindstrom, Ph.D., LLC,
hereinafter referred to as the "Contractor".
WHEREAS the parties entered into an Agreement for Mental Health Services, (the "Original
Agreement") identified by the Weld County Clerk to the Board of County Commissioners as
document No. 2014-3263, approved on October 22, 2014.
WHEREAS the parties hereby agree to amend the term of the Original Agreement in
accordance with the terms of the Original Agreement, which is incorporated by reference herein, as
well as the terms provided herein.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as
follows:
• The Original Agreement ended on May 31, 2015.
• The Original Agreement was renewed for the term of June 1, 2015 -May 31, 2016. The
Agreement Amendment is identified by the Weld County Clerk to the Board of County
Commissioners as document No. 2015-1851, approved on June 24, 2015.
• The Amendment, together with the Original Agreement, constitutes the entire
understanding between the parties. The following change is hereby made to the Contract
Documents:
1. Term
This agreement became effective on June 1, 2014, upon proper execution of this Agreement,
and shall expire May 31, 2017, unless sooner terminated as provided herein.
2. Exhibit D, Paragraph 2 — Fees for Services
$375.00/Hour (Ph.D. - Mental Health Assessment/Psychological Evaluation/Interactional
Evaluation)
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2016-1941
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$150.00/Hour (Ph.D. - Case Consultation)
$150.00/Hour (Ph.D. - Family Therapy)
$125.00/Hour (Ph.D. - Individual Therapy)
$95.00/Hour (M.S. - Family Therapy)
$75.00/Hour (M.S. - Individual Therapy)
$150.00/Hour (Ph.D. - Court Facilitation/Court Staffing/Family Team Meeting/Team
Decision Making Meeting)
$100.00/Hour (M.S. - Court Facilitation/Court Staffing/Family Team Meeting/Team
Decision Making Meeting.)
All other terms and conditions of the Original Agreement remain unchanged.
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
COUNTY:
ATTEST: j„ yti G •aC,LLO:ok BOARD OF COUNTY COMMISSIONERS
Weld C.. ty Clerk to the Board WELD COUNTY, COLORADO
By:
Deputy CI
Mike Freeman, Chair JUN 2 2 208
CONTRACTOR:
Barry R. Lindstrom, Ph.D., LLC
3211 20th Street, Suite D
Greeley, orado 8
By:
Date:
rry R. Lindstrom, Ph.D.
o?b/6-/9�/
ALLIED HEALTHCARE PROFESSIONAL AND SUPPLEMENTAL LIABILITY
INSURANCE POLICY DECLARATIONS
Policy Number: 072277 Philadelphia Indemnity Insurance Company
Administered by: CPH & Associates
711 S. Dearborn, Ste. 205
Chicago, IL 60605
Barry R. Lindstrom PhD, LLC
Barry Lindstrom
3211 20th St., Suite D
Greeley, CO 80634
Affiliation: ACA
Professional Occupation: Licensed Psychologist
Coverage Term From: 10/04/2015 to 10/04/2016
at 12:01 A.M. Standard Time at your mailing address shown above.
COVERAGE A - PROFESSIONAL LIABILITY COVERAGE
LIMITS OF
LIABILITY
PREMIUM
Individual - Each Incident:
SN/A
Aggregate:
$N/A
Association, Partnership or Corporation - Each Incident:.$I
Million
$1,155.00
Aggregate:
$3 Million
COVERAGE B - SUPPLEMENTAL LIABILITY COVERAGE
(Included)
Each Incident.$I
Million
Aggregate:
$3 Million
STATE LICENSING BOARD INVESTIGATION DEFENSE
COVERAGE
$75,000
$75.00
Premium (including taxes): $ 1,230.00
Policy Forms & Endorsements: PI-PHCP-O2 (07/10)
By:
2
Robert O'Leary, Authorized Representative
State Endorsement(s) made a part of this policy at the time of issue: refer to www.cphins.com
Call the Administrator to Verify Claims History at 1-800-875-1911
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TRAVELERS J One Towe Square, Hartford, Connecticut 06183
RENEWAL CERTIFICATE
COMMON POLICY DECLARATIONS POLICY NO.: 680-390N4113-15-42
OFFICE PAC ISSUE DATE: 09/04/2015
BUSINESS: PHYSICIANS AND
INSURING COMPANY:
THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
1. NAMED INSURED AND MAILING ADDRESS:
PATHWAYS MANAGEMENT
3211 20TH STREET SUITE D
GREELEY CO 80634
2. POLICY PERIOD:
3. LOCATIONS:
PREM.
NO.
001
BLDG.
NO.
001
From 11/01/2015 to 11/01/2016 12:01 A.M. Standard Time at your mailing address.
OCCUPANCY
ADDRESS (same as Mailing Address
unless specified otherwise)
OFFICE 3211 20TH STREET SUITE D
GREELEY CO 80634
4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING
COMPANIES
COVERAGE PARTS AND SUPPLEMENTS
INSURING COMPANY
Businessowners Coverage Part TCT
5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse -
ments for which symbol numbers are attached on a separate listing.
6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions.
POLICY POLICY NUMBER INSURING COMPANY
DIRECT BILL
7. PREMIUM SUMMARY:
Provisional Premium
Due at Inception
Due at Each
975.00
NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED BY:
FLOOD & PETERSON INS INC
PO BOX 578
GREELEY
IL TO 25 08 01 (Page 1 of 01)
Office: ELMIRA NY SRV CTR DOWN
XY235
CO 80632-0578
Authorized Representative
DATE: 09/04/2015
6690
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 680-390N4113-15-42 ISSUE DATE: 09/04/2015
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -DESIGNATED PERSON
OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of person or organization:
STATE OF COLORADO, WELD COUNTY, COLORADO BY AND THROUGH THE BOARD OF
PO BOX A CO 80632
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule as an insured but only with respect to liability arising out of your acts or omissions.
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CG T4 91 11 88
006698
Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1
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