15BCTS23Q00000016.pdf

15BCTS23Q00000016 Page 1 of 90

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 & 30

1. REQUISITION NUMBER PAGE 1 OF

5. SOLICITATION NUMBER

15BCTS23Q00000016

2. CONTRACT NO. 3. AWARD/EFFECTIVE

DATE

4. ORDER NUMBER 6. SOLICITATION ISSUE

DATE

03/28/2023

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

Kia Warner k1warner@bop.gov

b. TELEPHONE NUMBER (No collect calls)

202-598-6139

8. OFFER DUE DATE / LOCAL

TIME

04/28/2023 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 UNRESTRICTED OR X SET ASIDE: % FOR

X SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS (WOSB)

ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS: 621420

SIZE STANDARD: $19,000,000

10. THE ACQUISITION IS

SEE

SCHEDULE

11. DELIVERY FOR FOB DESTINATION

UNLESS BLOCK IS MARKED

016-23

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER DPAS

(15 CFR 700)

13b. RATING

X RFQ IFB RFP

14. METHOD OF SOLICITATION

15B500CODE15. DELIVER TO

Federal Bureau of Prisons South Central Regional Office 344 Marine Forces Drive Grand Prairie, TX 75051

CODE 15BCTS16. ADMINISTERED BY

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

Kia Warner

(O) 202-598-6139 k1warner@bop.gov

FACILITY

CODE

CODE

TELEPHONE NO.

17a. CONTRACTOR/

OFFEROR

15B500CODE18a. PAYMENT WILL BE MADE BY

Federal Bureau of Prisons South Central Regional Office 344 Marine Forces Drive Grand Prairie, TX 75051

BOP-RSD-CRBCTS-BILL-DAL

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 NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

Delivery Date: 06/01/2023

Substance Use, Mental Health, Medication Assistance and Sex Offender Treatment Services in San Antonio & Del Rio, TX 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 Govt. Use Only)

X 27a. SOLICITATION INCORPORATES BY REFERENCE 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: REF. _____________________________ 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)

Kia Warner

31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

15BCTS23Q00000016 Page 2 of 90

19.

ITEM NO.

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. 2/2012) BACK

15BCTS23Q00000016 Page 3 of 90

Table of Contents

Section Description Page Number

1 Solicitation/Contract Form 2 Commodity or Services Schedule 3 Contract Clauses

52.242-15 Stop-Work Order (Aug 1989) 52.21-603-70 Contracting Officer's Representative (COR) (June 2012) DOJ-05 Security of Department Information and Systems (APR 2015) 52.203-3 Gratuities (Apr 1984) 52.232-40 Providing Accelerated Payments to Small Business Subcontractors (Dec 2013) 52.253-1 Computer Generated Forms (Jan 1991) 52.212-4 Contract Terms and Conditions-Commercial Products and Commercial Services (Nov 2021) 52.203-12 Limitation On Payments To Influence Certain Federal Transactions (Oct 2010) 52.242-13 Bankruptcy (July 1995) 52.224-1 Privacy Act Notification (Apr 1984) 52.224-2 Privacy Act (Apr 1984) 52.204-12 Unique Entity Identifier Maintenance (Oct 2016) 52.204-13 System for Award Management Maintenance (Oct 2018) 52.216-18 Ordering (Oct 1995) 52.216-19 Order Limitations (Oct 1995) 52.217-8 Option to Extend Services (Nov 1999) 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)

BOP 2852.242-71 EVALUATION OF CONTRACTOR PERFORMANCE UTILIZING CPARS (APR

2011) 52.204-21 Basic Safeguarding of Covered Contractor Information Systems (June 2016) 52.217-9 Option to Extend the Term of the Contract (Mar 2000) DOJ-01 Whistleblower Information Distribution (Oct 2021) DOJ-03 Personnel Security Requirements For Contractor Employees (Nov 2021); (Alt. I) -- Classified Information -- Cleared Contractors 52.216-22 Indefinite Quantity (Oct 1995) DOJ-08 Continuing Contract Performance During a Pandemic Influenza or other National Emergency

(OCT 2007)

52.212-5 Contract Terms and Conditions Required To Implement Statutes or Executive Orders- Commercial Products and Commercial Services (Mar 2023)

4 List of Attachments 5 Solicitation Provisions

52.203-18 Prohibition on Contracting with Entities that Require Certain Internal Confidentiality Agreements or Statements--Representation (Jan 2017) 52.204-24 Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment (Dec 2019) 52.204-26 Covered Telecommunications Equipment or Services-Representation (Dec 2019) 52.209-7 Information Regarding Responsibility Matters (Oct 2018) 52.223-22 Public Disclosure of Greenhouse Gas Emissions and Reduction Goals-Representation (Dec 2016) 52.212-3 Offeror Representations and Certifications-Commercial Products and Commercial Services (Dec 2022) 52.204-16 Commercial and Government Entity Code Reporting (Jul 2016) 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 (Nov 2021) 52.233-2 Service of Protest (Sept 2006) 2852.233-70 Protests Filed Directly with the Department of Justice (Jan 1998) 52.216-1 Type of Contract (Apr 1984) 52.217-5 Evaluation of Options (July 1990)

15BCTS23Q00000016 Page 4 of 90

Section 2 - 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)

6 Units Guaranteed Minimum; 150 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0002 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0003 Substance Use Disorder Individual Counseling (2010)

240 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

240 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0004 Substance Use Disorder Intake Assessment & Report (2011)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0005 Co-occurring Intake Assessment & Report (2012)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

6 EA $________ $_________________

15BCTS23Q00000016 Page 5 of 90

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0006 Substance Use Disorder Group Counseling (2020)

180 Units Guaranteed Minimum; 3960 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

180 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

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0008 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 160 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0009 MAT - Intake Screening (4005)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0010 MAT Psychiatric Evaluation & Report (4050)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0011 Mental Health Treatment Planning and Follow-up (5001)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

2 EA $________ $_________________

15BCTS23Q00000016 Page 6 of 90

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0012 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 60 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0013 Mental Health Intake Assessment & Report (5011)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0014 Psychiatric Evaluation & Report (5030)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0015 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0016 Mental Health Individual Counseling (6010)

120 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

120 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0017 Mental Health Group Counseling (6020)

100 Units Guaranteed Minimum; 2200 Units Estimated Maximum

100 EA $________ $_________________

15BCTS23Q00000016 Page 7 of 90

Base Period: Date of award - 12 months Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0018 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0019 MH - Medication Monitoring & Report (6051)

2 Units Guaranteed Minimum; 240 Units Estimated Maximum

Base Period: Date of award - 12 months Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0020 Substance Use Disorder Treatment Planning and Follow-up (2001)

6 Units Guaranteed Minimum; 150 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0021 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0022 Substance Use Disorder Individual Counseling (2010)

240 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

240 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0023 Substance Use Disorder Intake Assessment & Report (2011) 6 EA $________ $_________________

15BCTS23Q00000016 Page 8 of 90

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0024 Co-occurring Intake Assessment & Report (2012)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0025 Substance Use Disorder Group Counseling (2020)

180 Units Guaranteed Minimum; 3960 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

180 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0026 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0027 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 160 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0028 MAT - Intake Screening (4005)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

15BCTS23Q00000016 Page 9 of 90

0029 MAT Psychiatric Evaluation & Report (4050)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0030 Mental Health Treatment Planning and Follow-up (5001)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0031 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 60 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0032 Mental Health Intake Assessment & Report (5011)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0033 Psychiatric Evaluation & Report (5030)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0034 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

1 EA $________ $_________________

15BCTS23Q00000016 Page 10 of 90

QUANTITY

UNIT UNIT PRICE AMOUNT

0035 Mental Health Individual Counseling (6010)

120 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

120 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0036 Mental Health Group Counseling (6020)

100 Units Guaranteed Minimum; 2200 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0037 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0038 MH - Medication Monitoring & Report (6051)

2 Units Guaranteed Minimum; 240 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0039 Substance Use Disorder Treatment Planning and Follow-up (2001)

6 Units Guaranteed Minimum; 150 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0040 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 2: Months 25 through 36

15BCTS23Q00000016 Page 11 of 90

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0041 Substance Use Disorder Individual Counseling (2010)

240 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

240 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0042 Substance Use Disorder Intake Assessment & Report (2011)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0043 Co-occurring Intake Assessment & Report (2012)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0044 Substance Use Disorder Group Counseling (2020)

180 Units Guaranteed Minimum; 3960 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

180 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0045 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0046 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 160 Units Estimated Maximum

15BCTS23Q00000016 Page 12 of 90

Option Year 2: Months 25 through 36 Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0047 MAT - Intake Screening (4005)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0048 MAT Psychiatric Evaluation & Report (4050)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0049 Mental Health Treatment Planning and Follow-up (5001)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0050 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 60 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0051 Mental Health Intake Assessment & Report (5011)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

0052 Psychiatric Evaluation & Report (5030) 2 EA $________ $_________________

15BCTS23Q00000016 Page 13 of 90

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0053 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0054 Mental Health Individual Counseling (6010)

120 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

120 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0055 Mental Health Group Counseling (6020)

100 Units Guaranteed Minimum; 2200 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0056 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0057 MH - Medication Monitoring & Report (6051)

2 Units Guaranteed Minimum; 240 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000016 Page 14 of 90

0058 Substance Use Disorder Treatment Planning and Follow-up (2001)

6 Units Guaranteed Minimum; 150 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0059 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0060 Substance Use Disorder Individual Counseling (2010)

240 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

240 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0061 Substance Use Disorder Intake Assessment & Report (2011)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0062 Co-occurring Intake Assessment & Report (2012)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0063 Substance Use Disorder Group Counseling (2020)

180 Units Guaranteed Minimum; 3960 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

180 EA $________ $_________________

15BCTS23Q00000016 Page 15 of 90

QUANTITY

UNIT UNIT PRICE AMOUNT

0064 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0065 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 160 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0066 MAT - Intake Screening (4005)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0067 MAT Psychiatric Evaluation & Report (4050)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0068 Mental Health Treatment Planning and Follow-up (5001)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0069 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 60 Units Estimated Maximum

Option Year 3: Months 37 through 48

15BCTS23Q00000016 Page 16 of 90

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0070 Mental Health Intake Assessment & Report (5011)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0071 Psychiatric Evaluation & Report (5030)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0072 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0073 Mental Health Individual Counseling (6010)

120 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

120 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0074 Mental Health Group Counseling (6020)

100 Units Guaranteed Minimum; 2200 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0075 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

15BCTS23Q00000016 Page 17 of 90

Option Year 3: Months 37 through 48 Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0076 MH - Medication Monitoring & Report (6051)

2 Units Guaranteed Minimum; 240 Units Estimated Maximum

Option Year 3: Months 37 through 48 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0077 Substance Use Disorder Treatment Planning and Follow-up (2001)

6 Units Guaranteed Minimum; 150 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0078 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0079 Substance Use Disorder Individual Counseling (2010)

240 Units Guaranteed Minimum; 3600 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

240 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0080 Substance Use Disorder Intake Assessment & Report (2011)

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

6 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

0081 Co-occurring Intake Assessment & Report (2012) 6 EA $________ $_________________

15BCTS23Q00000016 Page 18 of 90

6 Units Guaranteed Minimum; 75 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0082 Substance Use Disorder Group Counseling (2020)

180 Units Guaranteed Minimum; 3960 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

180 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0083 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0084 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 160 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0085 MAT - Intake Screening (4005)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0086 MAT Psychiatric Evaluation & Report (4050)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000016 Page 19 of 90

0087 Mental Health Treatment Planning and Follow-up (5001)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0088 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 60 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0089 Mental Health Intake Assessment & Report (5011)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0090 Psychiatric Evaluation & Report (5030)

2 Units Guaranteed Minimum; 80 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0091 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0092 Mental Health Individual Counseling (6010)

120 Units Guaranteed Minimum; 2400 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

120 EA $________ $_________________

15BCTS23Q00000016 Page 20 of 90

QUANTITY

UNIT UNIT PRICE AMOUNT

0093 Mental Health Group Counseling (6020)

100 Units Guaranteed Minimum; 2200 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

100 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0094 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0095 MH - Medication Monitoring & Report (6051)

2 Units Guaranteed Minimum; 240 Units Estimated Maximum

Option Year 4: Months 49 through 60 Location A

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0096 Substance Use Disorder Treatment Planning and Follow-up (2001)

3 Units Guaranteed Minimum; 75 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

3 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0097 Substance Use Disorder Intake Screening (2005)

1 Units Guaranteed Minimum; 25 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0098 Substance Use Disorder Individual Counseling (2010)

120 Units Guaranteed Minimum; 1800 Units Estimated Maximum

Potential 6 Month Extension

120 EA $________ $_________________

15BCTS23Q00000016 Page 21 of 90

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0099 Substance Use Disorder Intake Assessment & Report (2011)

3 Units Guaranteed Minimum; 38 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

3 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0100 Co-occurring Intake Assessment & Report (2012)

3 Units Guaranteed Minimum; 38 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

3 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0101 Substance Use Disorder Group Counseling (2020)

90 Units Guaranteed Minimum; 1980 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

90 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0102 Substance Use Disorder Relationship and Parenting Counseling (2030)

1 Units Guaranteed Minimum; 50 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0103 MAT – Follow-Up & Report (4004)

1 Units Guaranteed Minimum; 80 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0104 MAT - Intake Screening (4005)

1 Units Guaranteed Minimum; 20 Units Estimated Maximum

15BCTS23Q00000016 Page 22 of 90

Potential 6 Month Extension Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0105 MAT Psychiatric Evaluation & Report (4050)

1 Units Guaranteed Minimum; 20 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0106 Mental Health Treatment Planning and Follow-up (5001)

1 Units Guaranteed Minimum; 40 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0107 Mental Health Intake Screening (5005)

1 Units Guaranteed Minimum; 30 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0108 Mental Health Intake Assessment & Report (5011)

1 Units Guaranteed Minimum; 40 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0109 Psychiatric Evaluation & Report (5030)

1 Units Guaranteed Minimum; 40 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

0110 Crisis Intervention Evaluation & Report (6000) 1 EA $________ $_________________

15BCTS23Q00000016 Page 23 of 90

1 Unit Guaranteed Minimum; 5 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0111 Mental Health Individual Counseling (6010)

60 Units Guaranteed Minimum; 1200 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

60 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0112 Mental Health Group Counseling (6020)

50 Units Guaranteed Minimum; 1100 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0113 Mental Health Relationship and Parenting Counseling (6031)

1 Units Guaranteed Minimum; 50 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0114 MH - Medication Monitoring & Report (6051)

1 Units Guaranteed Minimum; 120 Units Estimated Maximum

Potential 6 Month Extension Location A

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0115 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 50 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

5 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000016 Page 24 of 90

0116 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 20 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0117 Substance Use Disorder Individual Counseling (2010)

20 Units Guaranteed Minimum; 600 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0118 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 25 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

5 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0119 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0120 Substance Use Disorder Group Counseling (2020)

20 Units Guaranteed Minimum; 1800 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0121 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

15BCTS23Q00000016 Page 25 of 90

QUANTITY

UNIT UNIT PRICE AMOUNT

0122 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 120 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0123 MAT - Intake Screening (4005)

1 Units Guaranteed Minimum; 20 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0124 MAT Psychiatric Evaluation & Report (4050)

1 Units Guaranteed Minimum; 20 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0125 Mental Health Treatment Planning and Follow-up (5001)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0126 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0127 Mental Health Intake Assessment & Report (5011)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

15BCTS23Q00000016 Page 26 of 90

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0128 Psychiatric Evaluation & Report (5030)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0129 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0130 Mental Health Individual Counseling (6010)

20 Units Guaranteed Minimum; 600 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0131 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0132 MH - Medication Monitoring & Report (6051)

2 Units Guaranteed Minimum; 120 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0133 Sex Offender Intake Assessment & Report (5012)

2 Units Guaranteed Minimum; 20 Units Estimated Maximum

Base Period: Date of award - 12 months

15BCTS23Q00000016 Page 27 of 90

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0134 Sex Offender Treatment Planning & Follow-up (6001)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0135 Sex Offender Intake Screening (6005)

2 Units Guaranteed Minimum; 20 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0136 Sex Offender Individual Counseling (6012)

2 Units Guaranteed Minimum; 320 Units Estimated Maximum

Base Period: Date of award - 12 months Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0137 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

5 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0138 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 20 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0139 Substance Use Disorder Individual Counseling (2010)

20 Units Guaranteed Minimum; 600 Units Estimated Maximum

20 EA $________ $_________________

15BCTS23Q00000016 Page 28 of 90

Option Year 1: Months 13 through 24 Location B

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0140 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 25 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

5 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0141 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0142 Substance Use Disorder Group Counseling (2020)

20 Units Guaranteed Minimum; 1800 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0143 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0144 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 120 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

15BCTS23Q00000016 Page 29 of 90

0145 MAT - Intake Screening (4005)

1 Units Guaranteed Minimum; 20 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0146 MAT Psychiatric Evaluation & Report (4050)

1 Units Guaranteed Minimum; 20 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0147 Mental Health Treatment Planning and Follow-up (5001)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0148 Mental Health Intake Screening (5005)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0149 Mental Health Intake Assessment & Report (5011)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0150 Psychiatric Evaluation & Report (5030)

2 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

15BCTS23Q00000016 Page 30 of 90

QUANTITY

UNIT UNIT PRICE AMOUNT

0151 Crisis Intervention Evaluation & Report (6000)

1 Unit Guaranteed Minimum; 10 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

1 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0152 Mental Health Individual Counseling (6010)

20 Units Guaranteed Minimum; 600 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0153 Mental Health Relationship and Parenting Counseling (6031)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0154 MH - Medication Monitoring & Report (6051)

2 Units Guaranteed Minimum; 120 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0155 Sex Offender Intake Assessment & Report (5012)

2 Units Guaranteed Minimum; 20 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0156 Sex Offender Treatment Planning & Follow-up (6001)

2 Units Guaranteed Minimum; 40 Units Estimated Maximum

Option Year 1: Months 13 through 24

15BCTS23Q00000016 Page 31 of 90

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0157 Sex Offender Intake Screening (6005)

2 Units Guaranteed Minimum; 20 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0158 Sex Offender Individual Counseling (6012)

2 Units Guaranteed Minimum; 320 Units Estimated Maximum

Option Year 1: Months 13 through 24 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0159 Substance Use Disorder Treatment Planning and Follow-up (2001)

5 Units Guaranteed Minimum; 50 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

5 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0160 Substance Use Disorder Intake Screening (2005)

2 Units Guaranteed Minimum; 20 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0161 Substance Use Disorder Individual Counseling (2010)

20 Units Guaranteed Minimum; 600 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0162 Substance Use Disorder Intake Assessment & Report (2011)

5 Units Guaranteed Minimum; 25 Units Estimated Maximum

Option Year 2: Months 25 through 36

5 EA $________ $_________________

15BCTS23Q00000016 Page 32 of 90

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0163 Co-occurring Intake Assessment & Report (2012)

2 Units Guaranteed Minimum; 25 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0164 Substance Use Disorder Group Counseling (2020)

20 Units Guaranteed Minimum; 1800 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0165 Substance Use Disorder Relationship and Parenting Counseling (2030)

2 Units Guaranteed Minimum; 100 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0166 MAT – Follow-Up & Report (4004)

2 Units Guaranteed Minimum; 120 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

2 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0167 MAT - Intake Screening (4005)

1 Units Guaranteed Minimum; 20 Units Estimated Maximum

Option Year 2: Months 25 through 36 Location B

PSC: G004

1…