1. Indianapolis IN 15BCTS23Q00000029.pdf

U. S. Department of Justice

Federal Bureau of Prisons

Washington, D.C. 20534

March 18, 2024

Re: 15BCTS23Q00000029, Indianapolis, IN

All Interested Parties:

This Request for Quotation (RFQ) is to provide Mental Health, Substance Use, and Sex Offender treatment services for male and female offenders held under authority of the United States in Indianapolis, Indiana. Services are to be provided in accordance with the enclosed Statement of Work entitled, “Federal Bureau of Prisons, Community Treatment Services, Statement of Work, 2022.”

The following must be completed and submitted with your Quotation:

Standard Form (SF) 1449 - Solicitation/Contract/Order for Commercial Items - Please complete blocks 12,17a, 17b, 23, 24, 30a, 30b, and 30c, of the SF-1449 and the continuation sheets. Please include your telephone number in Block 17a. Original signatures are required.

Quoter Representations and Certifications (FAR 52.212-3) - Prospective quoters are required to submit Annual Representations and Certifications at https://sam.gov/content/home. By submission of a quote under this solicitation, the quoter acknowledges completion of the annual representations and certifications via SAM and verifies, by the submission of the quote, that the representations and certifications currently posted in SAM were entered or updated within the last 12 months and are current, accurate, complete and applicable to this solicitation. All quoters must be capable of and comply with FAR 52.212‑1(j), Instructions to Offerors ‑ Commercial Items, Unique Entity Identifier (Sept 2023) and FAR 52.204‑7, System for Award Management (SAM) (Oct 2018).

Required Documentation Identified at Addendum to FAR 52.212-1, Instructions to Offerors - Commercial Services

Government shall award to the best value, responsive, and responsible quoter.

Electronic copies of quotations shall be submitted via email to yramos-maness@bop.gov in Adobe Acrobat (PDF) format. Email attachments (PDFs only) cannot total more than 14 MB per email.

Please compress PDFs when possible, to reduce the file size. We understand you will likely need to send multiple emails. Please confirm with the Contracting Officer that all emails and attachments were received.

Quotes will only be accepted via email. Please include SEPARATE FILE ATTACHMENTS for the following:

Completed SF-1449 Completed 2.1, Continuation of SF-1449 Completed Business Quotation Information Packet Completed Technical Quotation Information Packet Completed Past Performance Questionnaire Completed Small Business Subcontracting Plan Proof of completed SAM registration (must be Active by time of quotation submission) A copy of your current Professional Liability Insurance Completed Attachment Quotation Form

Quotations shall be received by Wednesday, April 17, 2024 at 2:00 PM EST to yramos-maness@bop.gov

The solicitation will be distributed solely through the General Services Administration’s www.SAM.gov website (sam.gov). Hard copies of the solicitation document will not be available.

The website provides downloading instructions.

All future information about this solicitation, including solicitation amendments, will be solely distributed through this website. Interested parties are responsible for monitoring this website to ensure they have the most up-to-date information about this solicitation.

Please direct any questions to yramos-maness@bop.gov. Please ensure to have the Notice ID (15BCTS23Q00000029) in the Subject line of all email correspondence.

Sincerely, Yasmin Ramos-Maness Contracting Officer

15BCTS23Q00000029 Page 1 of 74

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

NOTE: OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 AND 30.

1. REQUISITION NUMBER PAGE 1 OF

5. SOLICITATION NUMBER

15BCTS23Q00000029

2. CONTRACT NUMBER 3. AWARD/EFFECTIVE

DATE

4. ORDER NUMBER 6. SOLICITATION ISSUE

DATE

03/18/2024

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

Yasmin Ramos-Maness yramos-maness@bop.gov

b. TELEPHONE NUMBER (No collect calls)

202-598-5872

8. OFFER DUE DATE / LOCAL

TIME

04/17/2024 14:00 ET

CODE 15BCTS

Federal Bureau of Prisons

Community Treatment Services Contracting

320 First Street NW

Suite 901-5

Washington, DC 20534

9. ISSUED BY X UNRESTRICTED OR SET ASIDE: % FOR

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

(SDVOSB)

WOMEN-OWNED SMALL

BUSINESS (WOSB)

ECONOMICALLY DISADVANTAGED

WOMEN-OWNED SMALL BUSINESS

(EDWOSB)

8(A)

NORTH AMERICAN

INDUSTRY CLASSIFICATION

STANDARD (NAICS):

621420

SIZE STANDARD:

10. THE ACQUISITION IS

SEE SCHEDULE

11. DELIVERY FOR FREE ON BOARD

(FOB) DESTINATION UNLESS

BLOCK IS MARKED

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER THE

DEFENSE PRIORITIES AND

ALLOCATIONS SYSTEM -

DPAS (15 CFR 700)

13b. RATING

X REQUEST

FOR QUOTE

(RFQ)

INVITATION

FOR BID

(IFB)

REQUEST

FOR

PROPOSAL

(RFP)

14. METHOD OF SOLICITATION

15B100CODE15. DELIVER TO

Federal Bureau of Prisons Mid Atlantic Regional Office 302 Sentinel Drive Suite 200 Annapolis Junction, MD 20701

CODE 15BCTS16. ADMINISTERED BY

Federal Bureau of Prisons Community Treatment Services Contracting 320 First Street NW Suite 901-5 Washington, DC 20534

Yasmin Ramos-Maness

(O) 202-598-5872 yramos-maness@bop.gov

FACILITY

CODE

CODE

TELEPHONE NUMBER

17a. CONTRACTOR/

OFFEROR

15B100CODE18a. PAYMENT WILL BE MADE BY

Federal Bureau of Prisons Mid Atlantic Regional Office 302 Sentinel Drive Suite 200 Annapolis Junction, MD 20701

BOP-RSD-CRBCTS-BILL-DC@bop.gov

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN

OFFER SEE ADDENDUM

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK

BELOW IS CHECKED

19.

ITEM NUMBER

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

Delivery Date: 08/01/2024

Substance Use, Mental Health, and Sex Offender Treatment Services in Indianapolis, IN Firm Fixed Price

See Continuation Sheet(s) (Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AWARD AMOUNT (For Government Use Only)

X 27a. SOLICITATION INCORPORATES BY REFERENCE (FEDERAL ACQUISITION REGULATION) FAR 52.212-1, 52.212-4. FAR 52.212-3

AND 52.212-5 ARE ATTACHED. ADDENDA

ARE X ARE NOT ATTACHED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

X 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN 1 COPIES TO

ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET FORTH

OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT TO THE

TERMS AND CONDITIONS SPECIFIED.

29. AWARD OF CONTRACT: REFERENCE _____________________________

OFFER DATED _________________ . YOUR OFFER ON SOLICITATION (BLOCK

5) INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

HEREIN, IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30b. NAME AND TITLE OF SIGNER (Type or print) 30c. DATE SIGNED 31b. NAME OF THE CONTRACTING OFFICER (Type or print)

Yasmin Ramos-Maness

31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 11/2021)

Prescribed by GSA - FAR (48 CFR) 53.212

029-23

15BCTS23Q00000029 Page 2 of 74

19.

ITEM NUMBER

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: _________________________________

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

PARTIAL FINAL

33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED

CORRECT FOR

COMPLETE PARTIAL FINAL

36. PAYMENT 37. CHECK NUMBER

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 42a. RECEIVED BY (Print)

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 11/2021) BACK

15BCTS23Q00000029 Page 3 of 74

Table of Contents

Section Description Page Number

Solicitation/Contract Form 1 Commodity or Services Schedule 2 Contract Clauses

52.203-12 Limitation On Payments to Influence Certain Federal Transactions (Jun 2020) 52.204-12 Unique Entity Identifier Maintenance (Oct 2016) 52.212-4 Contract Terms and Conditions-Commercial Products and Commercial Services (Nov 2023) 52.224-1 Privacy Act Notification (Apr 1984) 52.224-2 Privacy Act (Apr 1984) 52.242-13 Bankruptcy (July 1995) 52.253-1 Computer Generated Forms (Jan 1991) 52.232-40 Providing Accelerated Payments to Small Business Subcontractors (Mar 2023) 52.203-3 Gratuities (Apr 1984) 52.242-15 Stop-Work Order (Aug 1989) 52.204-13 System for Award Management Maintenance (Oct 2018) 52.21-603-70 Contracting Officer's Representative (COR) (June 2012) 52.204-21 Basic Safeguarding of Covered Contractor Information Systems (Nov 2021)

BOP 2852.242-71 EVALUATION OF CONTRACTOR PERFORMANCE UTILIZING CPARS

(APR 2011)

DOJ-01 Whistleblower Information Distribution (Oct 2021) DOJ-03 Personnel Security Requirements For Contractor Employees (Nov 2021) 52.216-18 Ordering (Aug 2020) 52.216-19 Order Limitations (Oct 1995) 52.216-22 Indefinite Quantity (Oct 1995) 52.217-8 Option to Extend Services (Nov 1999) 52.217-9 Option to Extend the Term of the Contract (Mar 2000) 52.232-18 Availability of Funds (Apr 1984) 52.232-19 Availability of Funds for the Next Fiscal Year (Apr 1984) 52.237-7 Indemnification and Medical Liability Insurance (Jan 1997) DOJ-02 Contractor Privacy Requirements (JAN 2022) DOJ-08 Continuing Contract Performance During a Pandemic Influenza or other National Emergency (OCT 2007) DOJ-05 Security of Department Information and Systems DOJ-05 (OCT 2023) 52.203-17 Contractor Employee Whistleblower Rights (Nov 2023)

3 List of Attachments 4 Solicitation Provisions

52.203-18 Prohibition on Contracting with Entities that Require Certain Internal Confidentiality Agreements or Statements--Representation (Jan 2017) 52.204-16 Commercial and Government Entity Code Reporting (Aug 2020) 52.217-5 Evaluation of Options (July 1990) 52.204-22 Alternative Line Item Proposal (Jan 2017) 52.204-7 System for Award Management (Oct 2018) 52.212-1 Instructions to Offerors-Commercial Products and Commercial Services (Sep 2023) 52.204-24 Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment (Nov 2021) 52.216-1 Type of Contract (Apr 1984) 52.233-2 Service of Protest (Sept 2006) 2852.233-70 Protests Filed Directly with the Department of Justice (NOV 2020) 52.209-7 Information Regarding Responsibility Matters (Oct 2018) 52.204-29 Federal Acquisition Supply Chain Security Act Orders-Representation and Disclosures (Dec 2023) 52.212-3 Offeror Representations and Certifications-Commercial Products and Commercial Services (Nov 2023)

15BCTS23Q00000029 Page 4 of 74

Section 1 - Commodity or Services Schedule

SCHEDULE OF SUPPLIES/SERVICES

CONTINUATION SHEET

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0001 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0002 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 75 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

75 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0003 Substance Use Disorder Individual Counseling (2010)

120 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

3,600 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0004 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0005 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

50 EA $________ $_________________

15BCTS23Q00000029 Page 5 of 74

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0006 Substance Use Disorder Group Counseling (2020)

240 Units Guaranteed Minimum; 5280 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

5,280 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0007 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0008 Mental Health Treatment Planning and Follow-up (5001)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0009 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0010 Mental Health Intake Assessment & Report (5011)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

100 EA $________ $_________________

15BCTS23Q00000029 Page 6 of 74

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0011 Psychiatric Evaluation & Report (5030)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount. .

Base Period: Date of award - 12 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0012 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0013 Mental Health Individual Counseling (6010)

20 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0014 Case Management Services (6029)

2 Units Guaranteed Minimum; 250 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

250 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0015 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

15BCTS23Q00000029 Page 7 of 74

0016 MH - Administration of Medication (6050)

1 Unit Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0017 MH - Medication Monitoring & Report (6051)

5 Units Guaranteed Minimum; 200 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0018 Sex Offender Intake Assessment & Report (5012)

3 Unit Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0019 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0020 Sex Offender Intake Screening (6005)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Base Period: Date of award - 12 months

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0021 Sex Offender Individual Counseling (6012)

12 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total

2,400 EA $________ $_________________

15BCTS23Q00000029 Page 8 of 74 amount.

Base Period: Date of award - 12 months

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0022 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0023 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 75 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

75 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0024 Substance Use Disorder Individual Counseling (2010)

120 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

3,600 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0025 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0026 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

50 EA $________ $_________________

15BCTS23Q00000029 Page 9 of 74

QUANTITY

UNIT UNIT PRICE AMOUNT

0027 Substance Use Disorder Group Counseling (2020)

240 Units Guaranteed Minimum; 5280 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

5,280 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0028 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0029 Mental Health Treatment Planning and Follow-up (5001)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0030 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0031 Mental Health Intake Assessment & Report (5011)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000029 Page 10 of 74

0032 Psychiatric Evaluation & Report (5030)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount. .

Option Year 1: 13 months through 24 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0033 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0034 Mental Health Individual Counseling (6010)

20 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0035 Case Management Services (6029)

2 Units Guaranteed Minimum; 250 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

250 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0036 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0037 MH - Administration of Medication (6050)

1 Unit Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total

15BCTS23Q00000029 Page 11 of 74

Option Year 1: 13 months through 24 months

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0038 MH - Medication Monitoring & Report (6051)

5 Units Guaranteed Minimum; 200 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0039 Sex Offender Intake Assessment & Report (5012)

3 Unit Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0040 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0041 Sex Offender Intake Screening (6005)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0042 Sex Offender Individual Counseling (6012)

12 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 1: 13 months through 24 months

2,400 EA $________ $_________________

15BCTS23Q00000029 Page 12 of 74

QUANTITY

UNIT UNIT PRICE AMOUNT

0043 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0044 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 75 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

75 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0045 Substance Use Disorder Individual Counseling (2010)

120 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

3,600 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0046 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0047 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000029 Page 13 of 74

0048 Substance Use Disorder Group Counseling (2020)

240 Units Guaranteed Minimum; 5280 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

5,280 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0049 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0050 Mental Health Treatment Planning and Follow-up (5001)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0051 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0052 Mental Health Intake Assessment & Report (5011)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0053 Psychiatric Evaluation & Report (5030)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount. .

15BCTS23Q00000029 Page 14 of 74

Option Year 2: 25 months through 36 months

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0054 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0055 Mental Health Individual Counseling (6010)

20 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0056 Case Management Services (6029)

2 Units Guaranteed Minimum; 250 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

250 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0057 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0058 MH - Administration of Medication (6050)

1 Unit Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

15BCTS23Q00000029 Page 15 of 74

QUANTITY

UNIT UNIT PRICE AMOUNT

0059 MH - Medication Monitoring & Report (6051)

5 Units Guaranteed Minimum; 200 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0060 Sex Offender Intake Assessment & Report (5012)

3 Unit Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0061 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0062 Sex Offender Intake Screening (6005)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0063 Sex Offender Individual Counseling (6012)

12 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 2: 25 months through 36 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000029 Page 16 of 74

0064 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0065 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 75 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

75 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0066 Substance Use Disorder Individual Counseling (2010)

120 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

3,600 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0067 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0068 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0069 Substance Use Disorder Group Counseling (2020)

240 Units Guaranteed Minimum; 5280 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total

5,280 EA $________ $_________________

15BCTS23Q00000029 Page 17 of 74

Option Year 3: 37 months through 48 months

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0070 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0071 Mental Health Treatment Planning and Follow-up (5001)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0072 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0073 Mental Health Intake Assessment & Report (5011)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0074 Psychiatric Evaluation & Report (5030)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount. .

Option Year 3: 37 months through 48 months

15BCTS23Q00000029 Page 18 of 74

QUANTITY

UNIT UNIT PRICE AMOUNT

0075 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0076 Mental Health Individual Counseling (6010)

20 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0077 Case Management Services (6029)

2 Units Guaranteed Minimum; 250 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

250 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0078 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0079 MH - Administration of Medication (6050)

1 Unit Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000029 Page 19 of 74

0080 MH - Medication Monitoring & Report (6051)

5 Units Guaranteed Minimum; 200 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0081 Sex Offender Intake Assessment & Report (5012)

3 Unit Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0082 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0083 Sex Offender Intake Screening (6005)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0084 Sex Offender Individual Counseling (6012)

12 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 3: 37 months through 48 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0085 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

125 EA $________ $_________________

15BCTS23Q00000029 Page 20 of 74

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0086 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 75 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

75 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0087 Substance Use Disorder Individual Counseling (2010)

120 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

3,600 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0088 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0089 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0090 Substance Use Disorder Group Counseling (2020)

240 Units Guaranteed Minimum; 5280 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

5,280 EA $________ $_________________

15BCTS23Q00000029 Page 21 of 74

QUANTITY

UNIT UNIT PRICE AMOUNT

0091 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0092 Mental Health Treatment Planning and Follow-up (5001)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0093 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0094 Mental Health Intake Assessment & Report (5011)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0095 Psychiatric Evaluation & Report (5030)

5 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount. .

Option Year 4: 49 months through 60 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000029 Page 22 of 74

0096 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0097 Mental Health Individual Counseling (6010)

20 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0098 Case Management Services (6029)

2 Units Guaranteed Minimum; 250 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

250 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0099 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0100 MH - Administration of Medication (6050)

1 Unit Guaranteed Minimum; 100 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0101 MH - Medication Monitoring & Report (6051)

5 Units Guaranteed Minimum; 200 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total

200 EA $________ $_________________

15BCTS23Q00000029 Page 23 of 74

Option Year 4: 49 months through 60 months

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0102 Sex Offender Intake Assessment & Report (5012)

3 Unit Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0103 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0104 Sex Offender Intake Screening (6005)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0105 Sex Offender Individual Counseling (6012)

12 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Option Year 4: 49 months through 60 months

PSC: G004

2,400 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0106 Substance Use Disorder Treatment Planning and Follow-up (2001)

3 Units Guaranteed Minimum; 63 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

63 EA $________ $_________________

15BCTS23Q00000029 Page 24 of 74

QUANTITY

UNIT UNIT PRICE AMOUNT

0107 Substance Use Disorder Intake Screening (2005)

1 Unit Guaranteed Minimum; 38 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

38 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0108 Substance Use Disorder Individual Counseling (2010)

60 Units Guaranteed Minimum; 1800 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

1,800 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0109 Substance Use Disorder Intake Assessment & Report (2011)

3 Units Guaranteed Minimum; 63 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

63 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0110 Co-occurring Intake Assessment & Report (2012)

1 Unit Guaranteed Minimum; 25 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0111 Substance Use Disorder Group Counseling (2020)

210 Units Guaranteed Minimum; 2640 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

2,640 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000029 Page 25 of 74

0112 Substance Use Disorder Relationship and Parenting Counseling (2030)

1 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0113 Mental Health Treatment Planning and Follow-up (5001)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0114 Mental Health Intake Screening (5005)

1 Unit Guaranteed Minimum; 25 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0115 Mental Health Intake Assessment & Report (5011)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0116 Psychiatric Evaluation & Report (5030)

3 Units Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount. .

Potential 6 Month Extension

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0117 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 5 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total

5 EA $________ $_________________

15BCTS23Q00000029 Page 26 of 74

Potential 6 Month Extension

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0118 Mental Health Individual Counseling (6010)

10 Units Guaranteed Minimum; 1200 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0119 Case Management Services (6029)

1 Unit Guaranteed Minimum; 125 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

125 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0120 Mental Health Relationship and Parenting Counseling (6031)

1 Unit Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0121 MH - Administration of Medication (6050)

1 Unit Guaranteed Minimum; 50 Units Estimated Maximum

Use the Estimated Maximum Quantity when developing the total amount.

Potential 6 Month Extension

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0122 MH - Medication Monitoring & Report (6051)

3 Units Guaranteed Minimum; 100 Units…