APPENDIX B - Los Angeles County, California



APPENDIX DREQUIRED FORMS AND DOCUMENTSEXHIBITSPROPOSAL FORMS/EXHIBITS1Proposer’s Organization Questionnaire/Affidavit and CBE Information2Prospective Contractor References 3Prospective Contractor List of Contracts 4Prospective Contractor List of Terminated Contracts5Budget Form and Narrative6Financial Statements7Pending Litigation and Judgments StatementREQUIRED FORMS - EXHIBIT 1PROPOSER’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT AND CBE INFORMATIONPlease complete, sign and date this form. The person signing the form must be authorized to sign on behalf of the Proposer and to bind the applicant in a Contract.Is your firm a corporation or limited liability company (LLC)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Legal Name (found in Articles of Incorporation) __________________________________________State __________________________________________________ Year Inc. ________________If your firm is a limited partnership or a sole proprietorship, state the name of the proprietor or managing partner: ________________________________________________________________________________3.Is your firm doing business under one or more DBA’s? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Name County of Registration Year became DBA___________________________________ ________________________ ______________________________________________________ ________________________ ___________________4.Is your firm wholly/majority owned by, or a subsidiary of another firm? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Name of parent firm: _______________________________________________________________State of incorporation or registration of parent firm: _______________________________________5.Has your firm done business as other names within last five (5) years? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Name _________________________________________________ Year of Name Change ______Name _________________________________________________ Year of Name Change ______6.Is your firm involved in any pending acquisition or mergers, including the associated company name? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide information:________________________________________________________________________________________________________________________________________________________________Proposer acknowledges and certifies that firm meets and will comply with the Proposer’s Minimum Mandatory Qualifications as stated in Paragraph 3.0, of this Request for Services as listed below.Check the appropriate boxes: FORMCHECKBOX Yes FORMCHECKBOX No 3.1Proposer must have a current executed DMH Mental Health Services Act (MHSA) Master Agreement for the Workforce Education and Training – Infrastructure Component. DMH will verify. FORMCHECKBOX Yes FORMCHECKBOX No 3.2 Proposer must have 15 years’ experience offering trainings and certification(s) based on the Beckian model of Cognitive Behavioral Therapy (CBT), behavioral interventions, and a case conceptualization approach to treatment. 3.2.1Submit a sample training curriculum, provided within the last 15 years, that substantiates this experience. Label this submission as MMQ - 3.2. FORMCHECKBOX Yes FORMCHECKBOX No 3.3 Proposer must offer CBT certification(s) to multiple disciplines including but not limited to psychiatrists, psychologists, social workers, and marriage and family therapists.3.3.1Submit a list of disciplines eligible for CBT certification through Proposer’s training program(s). 3.3.2Indicate the number of participants by disciplines who have obtained certification within the last five (5) years. Label this submission as MMQ - 3.3. FORMCHECKBOX Yes FORMCHECKBOX No 3.4 Proposer must have a minimum of four (4) trainers who are CBT certified at both the practitioner and trainer level to deliver the services outlined in Appendix A - SOW. Trainers must have three (3) years of experience within the last five (5) years: 1) providing trainings and consultative services to those who serve ethnically and culturally diverse Serious Mental Illness (SMI) populations including nationally and internationally; 2) working in a variety of work settings and with populations that align with populations served in Los Angeles County (LAC); 3) have language capabilities to train and provide consultative services in Spanish plus three (3) other County threshold languages (i.e., Arabic, Armenian, Cantonese, Farsi, Khmer, Korean, Mandarin, other Chinese, Russian, Tagalog, and Vietnamese); and 4) have the capability to teach about cultural diversity in the context of CBT.3.4.1For each trainer, submit a copy of CBT certification(s) and curriculum vitae. Curriculum vitae must include: 1) work experiences; 2) work settings (including dates); 3) populations served; and 4) language capabilities. Examples of work experiences: direct service, teaching, training, consulting, research, etc. Examples of work settings: private practice, community mental health agency, university, etc.Label this submission as MMQ - 3.4. FORMCHECKBOX Yes FORMCHECKBOX No 3.5 Proposer must submit the Mandatory Letter of Intent (Appendix G) by the due date as indicated in Section 6.3 (RFS Timetable) and Section 6.6 (Mandatory Letter of Intent) of this RFS. DMH will verify. FORMCHECKBOX Yes FORMCHECKBOX No 3.6 If Proposer’s compliance with a County contract has been reviewed by the Department of the Auditor-Controller (A-C) within the last 10 years, Proposer must not have unresolved questioned costs identified by the A-C, in an amount over $100,000 that are confirmed to be disallowed costs by the contracting County department, and remain unpaid for six (6) months or more from the date of disallowance, unless such disallowed costs are the subject of current good faith negotiations to resolve the disallowed costs, in the opinion of the County. DMH will verify.I.FIRM/ORGANIZATION INFORMATION: The information requested below is for statistical purposes only. On final analysis and consideration of award, contractor/vendor will be selected without regard to race/ethnicity, color, religion, sex, national origin, age, sexual orientation or disability.Business Structure: Sole Proprietorship Partnership Corporation Non-Profit Franchise Other (Specify) ___________________________________________________________________Total Number of Employees (including owners):Race/Ethnic Composition of Firm. Distribute the above total number of individuals into the following categories:Race/Ethnic CompositionOwners/Partners/Associate PartnersManagersStaffMaleFemaleMaleFemaleMaleFemaleBlack/African American??????Hispanic/Latino??????Asian or Pacific Islander??????American Indian??????Filipino??????White??????II.PERCENTAGE OF OWNERSHIP IN FIRM: Please indicate by percentage (%) how ownership of the firm is distributed.Black/African AmericanHispanic/ LatinoAsian or Pacific IslanderAmerican IndianFilipinoWhiteMen%%%%%%Women%%%%%%CERTIFICATION AS MINORITY, WOMEN, DISADVANTAGED, AND DISABLED VETERAN BUSINESS ENTERPRISES: If your firm is currently certified as a minority, women, disadvantaged or disabled veteran owned business enterprise by a public agency, complete the following and attach a copy of your proof of certification. (Use back of form, if necessary.)Agency NameMinorityWomenDisadvantagedDisabled VeteranOtherProposer further acknowledges that if any false, misleading, incomplete, or deceptively unresponsive statements in connection with this proposal are made, the proposal may be rejected. The evaluation and determination in this area shall be at the Director’s sole judgment and his judgment shall be final.DECLARATION: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.PROPOSER NAME:COUNTY WEBVEN NUMBER:ADDRESS:PHONE NUMBER:E-MAIL:INTERNAL REVENUE SERVICE EMPLOYER IDENTIFICATION NUMBER:CALIFORNIA BUSINESS LICENSE NUMBER:PROPOSER OFFICIAL NAME AND TITLE (PRINT):SIGNATUREDATEREQUIRED FORMS - EXHIBIT 2PROSPECTIVE CONTRACTOR REFERENCESContractor’s Name: _______________________________List three (3) References where the same or similar scope of services were provided as stated in this RFS.1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.REQUIRED FORMS - EXHIBIT 3PROSPECTIVE CONTRACTOR LIST OF CONTRACTSContractor’s Name: _______________________________List of all public entities for which the Contractor has provided service within the last three (3) years. Use additional sheets if necessary.1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.4. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.5. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.REQUIRED FORMS - EXHIBIT 4PROSPECTIVE CONTRACTOR LIST OF TERMINATED CONTRACTSContractor’s Name: ______________________________List of all contracts that have been terminated within the past three (3) years.1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:4. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:REQUIRED FORMS - EXHIBIT 5BUDGET FORM AND NARRATIVE Proposer must provide a narrative explaining ALL proposed budget costs.GENERAL INFORMATION Proposer must provide a budget for the proposed Mental Health Services Act (MHSA) funded Individual Cognitive Behavioral Therapy (ICBT) Training and Consultative Services.The proposed budgets must clearly reflect the Proposer’s costs to provide ICBT training and consultative services for three (3) Fiscal Years (FYs). The budget cannot exceed the anticipated Maximum Allocated Funding of $625,151 for each FY, a total of $1,875,453 for three (3) FYs as stated in the Request for Services (RFS), Section 2.2.4 (Anticipated Funding). Budget amount for FY 1 will be prorated based on the date of board approval of awardee and the balance will be carried forward to subsequent FYs. Proposer shall provide a Budget Narrative as an attachment to the Budget Form (Appendix D – Required Forms and Documents - Exhibit 5). The Budget Narrative must include the computations showing how each dollar amount that appears on the Budget Form was calculated, and must describe how each line item category will be used to fulfill the deliverables in Appendix A (Statement of Work). All amounts are to be rounded off to the nearest dollar. The following are explanations of the allowable line item categories per FY. Proposer is responsible for the accuracy of all information presented in the Budget Form and Narrative. I. DIRECT COSTS1. TRAINING FOR INITIAL ICBT COHORTS 1.1 3-Day Initial ICBT Training Proposer shall conduct five (5) 3-Day ICBT Initial training sessions with attendance of up to 60 clinicians at each session for a total of 300 clinicians. 1.2 Training Materials Proposer shall provide the mandatory textbooks and manuals for all the ICBT 3-Day Initial trainings. Each clinician shall be provided with the following materials: Cognitive Behavior Therapy, Second Edition by Judith S. Beck Overcoming Resistance in Cognitive Therapy by Robert L. Leahy 1.3 Booster Training Proposer shall conduct five (5) ICBT Booster trainings with attendance by up to 60 clinicians at each session for a total of 300 clinicians. A Booster training for each cohort of ICBT Initial training is required. 2. CONSULTATIVE SERVICES FOR INITIAL ICBT COHORTS 2.1 Consultation Calls Proposer shall conduct consultation calls with DMH and contract providers for each cohort of up to 60 clinicians, not to exceed eight (8) clinicians per call group. The 60 clinicians shall be distributed amongst a maximum of eight (8) call groups per cohort for 16 weeks, totaling 560 hours of consultation calls for five (5) cohorts. Each call must be at least 50 minutes. 2.2 Audio Recording Review Proposer shall review three (3) audio recordings per clinician and provide scores to DMH for up to 300 clinicians trained per FY, and up to 900 audio recording reviews total over three (3) FYs. 2.3 Case Conceptualization Review Proposer shall review three (3) case conceptualization reviews per clinician and provide scores to DMH for up to 300 clinicians trained per FY, and up to 900 reviews total over three (3) FYs. 3. CONSULTATIVE SERVICES FOR ICBT CLINICAL CHAMPION 3.1 Consultation Calls Proposer shall conduct consultation calls with DMH and Legal Entity providers for each Clinical Champion (CC) cohort of up to 10 CC per FY, with maximum of five (5) CC clinicians per call group. The 10 CCs shall be distributed amongst a maximum of two (2) call groups per cohort for 10 weeks, totaling 40 hours of consultation calls for two (2) cohorts. Each call must be at least 50 minutes. 3.2 Audio Recording Review Proposer shall review one (1) audio recording and provide scores to DMH for up to 20 CC clinicians trained for a total of 20 audio recording reviews per FY. 3.3 Supervisory Case Conceptualization Review Proposer shall review one (1) personal supervisory model and provide scores for up to 20 CC clinicians trained for a total of 20 reviews per FY. 3.4 Training Materials Proposer shall provide 20 copies of the Teaching and Supervising Cognitive Behavior Therapy By Donna M. Sudak and R. Trent Codd III manuals for the ICBT CC trainings. 4. CERTIFICATION Proposer shall provide the application to become a certified CBT therapist at a rate of $350 per certification application. II. INDIRECT COSTS Administrative support and other indirect costs are those incurred for the common benefit of the organization’s total contracted ICBT services and are not directly or readily attributable to a previously specified direct cost. Allowable administrative costs include accounting, budgeting, information system, and other such similar services. These costs must be reasonable and compliant with federal cost allocation principles. Administrative costs are allowable to the extent they are: 1) reasonable; and 2) related to the services provided by the providers. Indirect costs shall not exceed 15% of the total cost per FY. ADMINISTRATIVE COSTSAdministrative costs are the indirect costs related to the implementation and operation of the program. Such costs must be reasonable and include a formula on how the cost was calculated.OTHER INDIRECT COSTSSpecify other indirect costs and provide a justification for such costs and the benefits to the program proposed under this RFS.REQUIRED FORMS - EXHIBIT 5BUDGET FORMBUDGET CATEGORIESYEAR 1 YEAR 2YEAR 3 3 YEARS TOTALDIRECT COSTS1.TRAININGS FOR INITIAL ICBT COHORTS (Based on 300 clinicians per FY)????1.13-Day Initial ICBT Training?1.2Training Materials 1.3Booster Training ??SUBTOTAL ???2.CONSULTATIVE SERVICES FOR INITIAL ICBT COHORTS (Based on 300 clinicians per FY)2.1Consultation Calls2.2Audio Recording Review 2.3Case Conceptualization ReviewSUBTOTAL 3.CONSULTATIVE SERVICES FOR ICBT CC (Based on 20 CC per FY)?3.1 Consultation Calls?3.2 Audio Recording Review?3.3 Supervisory Case Conceptualization Review3.4 Training Materials SUBTOTAL4.CERTIFICATIONSINDIRECT COSTS???Administrative Costs (basis for Admin Fee)???Other Indirect Costs (specify)???SUBTOTAL:????TOTAL MAXIMUM ALLOCATIONNote: Indirect Costs shall not exceed 15% of the total cost per FY. Budget amount for the first year will be prorated based on the date of board approval of awardee and the balance will be carried forward to subsequent FYs.EXHIBIT 6ATTACH FINANCIAL STATEMENTSEXHIBIT 7ATTACH PENDING LITIGATION AND JUDGMENT STATEMENT ................
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