15BCTS26Q00000006 Oklahoma City OK.pdf

15BCTS26Q00000006 Page 1 of 45

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

15BCTS26Q00000006

2. CONTRACT NUMBER 3. AWARD/EFFECTIVE

DATE

4. ORDER NUMBER 6. SOLICITATION ISSUE

DATE

11/09/2026

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

Coretta MaGee cmagee@bop.gov

b. TELEPHONE NUMBER (No collect calls)

202-598-6114

8. OFFER DUE DATE / LOCAL

TIME

12/09/2026 12:00 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:100.00 % FOR

X 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:

19,000,000

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

CODE15. DELIVER TO CODE 15BCTS16. ADMINISTERED BY

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

Coretta MaGee

(O) 202-598-6114 cmagee@bop.gov

FACILITY

CODE

CODE

TELEPHONE NUMBER

17a. CONTRACTOR/

OFFEROR

15B200CODE18a. PAYMENT WILL BE MADE BY

Federal Bureau of Prisons Northeast Regional Office

US CUSTOM HOUSE, 7TH FLOOR

2ND & CHESTNUT

Philadelphia, PA 19106

BOP-RSD-CRBCTS-BILL-DAL-

S@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: 01/01/2027

Outpatient Substance Use Disorder (SU) & Mental Health (MH) Services in Oklahoma City, OK 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)

Coretta MaGee

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

0006-26

15B200 Federal Bureau of Prisons Northeast Regional Office

US CUSTOM HOUSE, 7TH FLOOR

2ND & CHESTNUT

Philadelphia, PA 19106

UEI:

15BCTS26Q00000006 Page 2 of 45

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

15BCTS26Q00000006 Page 3 of 45

Table of Contents

Section Description Page Number

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

52.203-6 Alt I Restrictions on Subcontractor Sales to the Government (Jun 2020) - Alternate I (Nov 2021) 52.203-13 Contractor Code of Business Ethics and Conduct (Nov 2021) 52.204-13 (DEV) System for Award Management-Maintenance (Oct 2018) (DEVIATION NOV 2025) 52.204-19 Incorporation by Reference of Representations and Certifications (Dec 2014) 52.204-91 (DEV) Contractor Identification (DEVIATION NOV 2025) 52.209-6 (DEV) Protecting the Government's Interest When Subcontracting with Contractors Debarred, Suspended, Proposed for Debarment, or Voluntarily Excluded (Jan 2025)

(DEVIATION NOV 2025)

52.209-9 (DEV) Updates of Publicly Available Information Regarding Responsibility Matters (Oct 2018) (DEVIATION NOV 2025) 52.209-10 (DEV) Prohibition on Contracting With Inverted Domestic Corporations (Nov 2015)

(DEVIATION NOV 2025)

52.219-6 (DEV) Notice of Total Small Business Set-Aside (Nov 2020) (DEVIATION DEC 2025) 52.219-8 (DEV) Utilization of Small Business Concerns (Jan 2025) (DEVIATION DEC 2025) 52.222-3 (DEV) Convict Labor (June 2003) (DEVIATION DEC 2025) 52.222-19 (DEV) Child Labor-Cooperation with Authorities and Remedies (Jan 2025)

(DEVIATION MAR 2026)

52.222-35 (DEV) Equal Opportunity for Veterans (Jun 2020) (DEVIATION DEC 2025) 52.222-36 (DEV) Equal Opportunity for Workers with Disabilities (Jun 2020) (DEVIATION

DEC 2025)

52.222-37 (DEV) Employment Reports on Veterans (Jun 2020) (DEVIATION DEC 2025) 52.222-40 (DEV) Notification of Employee Rights Under the National Labor Relations Act (Dec

2010) (DEVIATION DEC 2025)

52.222-41 (DEV) Service Contract Labor Standards (Aug 2018) (DEVIATION DEC 2025) 52.222-50 (DEV) Combating Trafficking in Persons (Oct 2025) (DEVIATION DEC 2025) 52.222-54 (DEV) Employment Eligibility Verification (Jan 2025) (DEVIATION DEC 2025) 52.222-90 Addressing DEI Discrimination by Federal Contractors (APR 2026) 52.224-3 Privacy Training (Jan 2017) 52.226-8 Encouraging Contractor Policies To Ban Text Messaging While Driving (May 2024) 52.232-33 Payment by Electronic Funds Transfer-System for Award Management (Oct 2018) 52.232-40 Providing Accelerated Payments to Small Business Subcontractors (Mar 2023) 52.233-3 (DEV) Protest after Award (Aug 1996) (DEVIATION NOV 2025) 52.233-4 (DEV) Applicable Law for Breach of Contract Claim (Oct 2004) (DEVIATION NOV 2025) 52.240-91 (DEV) Security Prohibitions and Exclusions (DEVIATION NOV 2025) 52.240-93 (DEV) Basic Safeguarding of Covered Contractor Information Systems

(DEVIATION NOV 2025)

52.242-13 Bankruptcy (July 1995) 52.242-15 Stop-Work Order (Aug 1989) 52.252-6 Authorized Deviations in Clauses (Nov 2020) 52.212-4 (DEV) Terms and Conditions-Commercial Products and Commercial Services (Nov

2023) (DEVIATION NOV 2025)

52.253-1 (DEV) Computer Generated Forms (Jan 1991) (DEVIATION NOV 2025) 52.216-18 Ordering (Aug 2020) 52.216-19 Order Limitations (Oct 1995)

15BCTS26Q00000006 Page 4 of 45

52.216-22 (DEV) Indefinite Quantity (Oct 1995) (DEVIATION DEC 2025) 52.217-8 Option to Extend Services (Nov 1999) 52.232-18 Availability of Funds (Apr 1984) 52.237-7 (DEV) Indemnification and Medical Liability Insurance (Jan 1997) (DEVIATION NOV 2025) BOP 2852.201-71 Contracting Officer's Representative (COR) (June 2012)

BOP 2852.242-71 EVALUATION OF CONTRACTOR PERFORMANCE UTILIZING CPARS

(APR 2011)

BOP DOJ-05 DEVIATION BOP-05 Security of Department Information and Systems (January 2025) DOJ-01 Whistleblower Information Distribution (Oct 2021) DOJ-02 Contractor Privacy Requirements (JAN 2022) DOJ-03 Personnel Security Requirements For Contractor Employees (Nov 2021) DOJ-08 Continuing Contract Performance During a Pandemic Influenza or other National Emergency (OCT 2007) 52.217-9 Option to Extend the Term of the Contract (Mar 2000)

3 List of Attachments 4 Solicitation Provisions

52.203-11 Certification And Disclosure Regarding Payments to Influence Certain Federal Transactions (Sept 2024) 52.203-18 Prohibition on Contracting with Entities that Require Certain Internal Confidentiality Agreements or Statements--Representation (Jan 2017) 52.204-7 (DEV) System for Award Management-Registration (Nov 2024) (DEVIATION NOV 2025) 52.217-5 (DEV) Evaluation of Options (July 1990) (DEVIATION AUG 2025) 52.219-4 (DEV) Notice of Price Evaluation Preference for HUBZone Small Business Concerns (Oct 2022) (DEVIATION DEC 2025) 52.233-2 (DEV) Service of Protest (Sep 2006) (DEVIATION NOV 2025) 52.240-90 (DEV) Security Prohibitions and Exclusions Representations and Certifications

(DEVIATION NOV 2025)

2852.233-70 Protests Filed Directly with the Department of Justice (NOV 2020) 52.212-1 (DEV) Instructions to Offerors-Commercial Products and Commercial Services (Sep

2023) (DEVIATION NOV 2025)

52.209-11 (DEV) Representation by Corporations Regarding Delinquent Tax Liability or a Felony Conviction under any Federal Law (Feb 2016) (DEVIATION NOV 2025) 52.216-1 (DEV) Type of Contract (Apr 1984) (DEVIATION DEC 2025)

15BCTS26Q00000006 Page 5 of 45

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)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0002 Substance Use Disorder Intake Screening (2005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0003 Substance Use Disorder Individual Counseling (2010)

Guaranteed Minimum; Quantity: 120 Estimated Maximum Quantity: 1200

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0004 Substance Use Disorder Intake Assessment & Report (2011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0005 Co-occurring Intake Assessment & Report (2012)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

25 EA $________ $_________________

15BCTS26Q00000006 Page 6 of 45

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0006 Substance Use Disorder Group Counseling (2020)

Guaranteed Minimum Quantity: 144 Estimated Maximum Quantity: 1800

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,800 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0007 Substance Use Disorder Relationship and Parenting Counseling (2030)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

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

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

BaseYear: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0009 Mental Health Intake Screening (5005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 50

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0010 Mental Health Intake Assessment & Report (5011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Base Year: Date of award - 12 months

80 EA $________ $_________________

15BCTS26Q00000006 Page 7 of 45

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0011 Psychiatric Evaluation & Report (5030)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0012 Crisis Intervention Evaluation & Report (6000)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0013 Mental Health Individual Counseling (6010)

Guaranteed Minimum Quantity: 80 Estimated Maximum Quantity: 1200

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0014 Mental Health Group Counseling (6020)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 480

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

480 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0015 Mental Health Relationship and Parenting Counseling (6031)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

36 EA $________ $_________________

15BCTS26Q00000006 Page 8 of 45

PSC: G004

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0016 MH - Medication Monitoring & Report (6051)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 300

Base Year: Date of award - 12 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

300 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0017 Substance Use Disorder Treatment Planning and Follow-up (2001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0018 Substance Use Disorder Intake Screening (2005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0019 Substance Use Disorder Individual Counseling (2010)

Guaranteed Minimum; Quantity: 120 Estimated Maximum Quantity: 1200

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0020 Substance Use Disorder Intake Assessment & Report (2011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

40 EA $________ $_________________

15BCTS26Q00000006 Page 9 of 45

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0021 Co-occurring Intake Assessment & Report (2012)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0022 Substance Use Disorder Group Counseling (2020)

Guaranteed Minimum Quantity: 144 Estimated Maximum Quantity: 1800

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,800 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0023 Substance Use Disorder Relationship and Parenting Counseling (2030)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0024 Mental Health Treatment Planning and Follow-up (5001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0025 Mental Health Intake Screening (5005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 50

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

50 EA $________ $_________________

15BCTS26Q00000006 Page 10 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0026 Mental Health Intake Assessment & Report (5011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0027 Psychiatric Evaluation & Report (5030)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0028 Crisis Intervention Evaluation & Report (6000)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0029 Mental Health Individual Counseling (6010)

Guaranteed Minimum Quantity: 80 Estimated Maximum Quantity: 1200

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0030 Mental Health Group Counseling (6020)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 480

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

480 EA $________ $_________________

15BCTS26Q00000006 Page 11 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0031 Mental Health Relationship and Parenting Counseling (6031)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0032 MH - Medication Monitoring & Report (6051)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 300

Option Year 1: 13 - 24 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

300 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0033 Substance Use Disorder Treatment Planning and Follow-up (2001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0034 Substance Use Disorder Intake Screening (2005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0035 Substance Use Disorder Individual Counseling (2010)

Guaranteed Minimum; Quantity: 120 Estimated Maximum Quantity: 1200

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

1,200 EA $________ $_________________

15BCTS26Q00000006 Page 12 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0036 Substance Use Disorder Intake Assessment & Report (2011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0037 Co-occurring Intake Assessment & Report (2012)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0038 Substance Use Disorder Group Counseling (2020)

Guaranteed Minimum Quantity: 144 Estimated Maximum Quantity: 1800

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,800 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0039 Substance Use Disorder Relationship and Parenting Counseling (2030)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0040 Mental Health Treatment Planning and Follow-up (5001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

15BCTS26Q00000006 Page 13 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0041 Mental Health Intake Screening (5005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 50

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0042 Mental Health Intake Assessment & Report (5011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0043 Psychiatric Evaluation & Report (5030)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0044 Crisis Intervention Evaluation & Report (6000)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0045 Mental Health Individual Counseling (6010)

Guaranteed Minimum Quantity: 80 Estimated Maximum Quantity: 1200

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

1,200 EA $________ $_________________

15BCTS26Q00000006 Page 14 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0046 Mental Health Group Counseling (6020)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 480

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

480 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0047 Mental Health Relationship and Parenting Counseling (6031)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0048 MH - Medication Monitoring & Report (6051)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 300

Option Year 2: 25 - 36 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

300 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0049 Substance Use Disorder Treatment Planning and Follow-up (2001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0050 Substance Use Disorder Intake Screening (2005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

25 EA $________ $_________________

15BCTS26Q00000006 Page 15 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0051 Substance Use Disorder Individual Counseling (2010)

Guaranteed Minimum; Quantity120 Estimated Maximum Quantity: 1200

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0052 Substance Use Disorder Intake Assessment & Report (2011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0053 Co-occurring Intake Assessment & Report (2012)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0054 Substance Use Disorder Group Counseling (2020)

Guaranteed Minimum Quantity: 144 Estimated Maximum Quantity: 1800

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,800 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0055 Substance Use Disorder Relationship and Parenting Counseling (2030)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

36 EA $________ $_________________

15BCTS26Q00000006 Page 16 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0056 Mental Health Treatment Planning and Follow-up (5001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0057 Mental Health Intake Screening (5005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 50

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0058 Mental Health Intake Assessment & Report (5011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0059 Psychiatric Evaluation & Report (5030)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0060 Crisis Intervention Evaluation & Report (6000)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

10 EA $________ $_________________

15BCTS26Q00000006 Page 17 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0061 Mental Health Individual Counseling (6010)

Guaranteed Minimum Quantity: 80 Estimated Maximum Quantity: 1200

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0062 Mental Health Group Counseling (6020)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 480

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

480 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0063 Mental Health Relationship and Parenting Counseling (6031)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0064 MH - Medication Monitoring & Report (6051)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 300

Option Year 3: 37 - 48 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

300 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0065 Substance Use Disorder Treatment Planning and Follow-up (2001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

15BCTS26Q00000006 Page 18 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0066 Substance Use Disorder Intake Screening (2005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0067 Substance Use Disorder Individual Counseling (2010)

Guaranteed Minimum; Quantity: 120 Estimated Maximum Quantity: 1200

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0068 Substance Use Disorder Intake Assessment & Report (2011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 40

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0069 Co-occurring Intake Assessment & Report (2012)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 25

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0070 Substance Use Disorder Group Counseling (2020)

Guaranteed Minimum Quantity: 144 Estimated Maximum Quantity: 1800

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

1,800 EA $________ $_________________

15BCTS26Q00000006 Page 19 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0071 Substance Use Disorder Relationship and Parenting Counseling (2030)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0072 Mental Health Treatment Planning and Follow-up (5001)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0073 Mental Health Intake Screening (5005)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 50

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

50 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0074 Mental Health Intake Assessment & Report (5011)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

80 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0075 Psychiatric Evaluation & Report (5030)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 80

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

15BCTS26Q00000006 Page 20 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0076 Crisis Intervention Evaluation & Report (6000)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 10

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

10 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0077 Mental Health Individual Counseling (6010)

Guaranteed Minimum Quantity: 80 Estimated Maximum Quantity: 1200

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

1,200 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0078 Mental Health Group Counseling (6020)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 480

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

480 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0079 Mental Health Relationship and Parenting Counseling (6031)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 36

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

36 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0080 MH - Medication Monitoring & Report (6051)

Guaranteed Minimum Quantity: 4 Estimated Maximum Quantity: 300

Option Year 4: 49 - 60 months

Use the Estimated Maximum Quantity when developing the total amount.

300 EA $________ $_________________

15BCTS26Q00000006 Page 21 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0081 Substance Use Disorder Treatment Planning and Follow-up (2001)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 20

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0082 Substance Use Disorder Intake Screening (2005)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 13

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

13 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0083 Substance Use Disorder Individual Counseling (2010)

Guaranteed Minimum; Quantity: 60 Estimated Maximum Quantity: 600

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

600 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0084 Substance Use Disorder Intake Assessment & Report (2011)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 20

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

20 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0085 Co-occurring Intake Assessment & Report (2012)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 13

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

13 EA $________ $_________________

15BCTS26Q00000006 Page 22 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0086 Substance Use Disorder Group Counseling (2020)

Guaranteed Minimum Quantity: 72 Estimated Maximum Quantity: 900

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

900 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0087 Substance Use Disorder Relationship and Parenting Counseling (2030)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 18

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

18 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0088 Mental Health Treatment Planning and Follow-up (5001)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 40

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0089 Mental Health Intake Screening (5005)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 25

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

25 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0090 Mental Health Intake Assessment & Report (5011)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 40

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

15BCTS26Q00000006 Page 23 of 45

QUANTITY

UNIT UNIT PRICE AMOUNT

0091 Psychiatric Evaluation & Report (5030)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 40

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

40 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0092 Crisis Intervention Evaluation & Report (6000)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 5

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

5 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0093 Mental Health Individual Counseling (6010)

Guaranteed Minimum Quantity: 40 Estimated Maximum Quantity: 600

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

600 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0094 Mental Health Group Counseling (6020)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 240

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

PSC: G004

240 EA $________ $_________________

ITEM NO. SUPPLIES/SERVICES EST.

QUANTITY

UNIT UNIT PRICE AMOUNT

0095 Mental Health Relationship and Parenting Counseling (6031)

Guaranteed Minimum Quantity: 1 Estimated Maximum Quantity: 18

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

18 EA $________ $_________________

15BCTS26Q00000006 Page 24 of 45

ITEM NO. SUPPLIES/SERVICES EST. UNIT UNIT PRICE AMOUNT

0096 MH - Medication Monitoring & Report (6051)

Guaranteed Minimum Quantity: 2 Estimated Maximum Quantity: 150

Potential Six-Month Extension

Use the Estimated Maximum Quantity when developing the total amount.

150 EA $________ $_________________

15BCTS26Q00000006 Page 25 of 45

Section 2 - Contract Clauses

A.1 ADDENDUM TO FAR 52.212-4, Terms and Conditions-Commercial Products and Commercial Services (Nov

2023) (DEVIATION NOV 2025)

The terms and conditions for the following clauses are hereby incorporated into this solicitation and resulting contract as an addendum to FAR clause 52.212-4.

Clauses By Reference

52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/these address(es): www.acquisition.gov

Clause Title Fill-ins (if applicable)

52.203-6 Alt I Restrictions on Subcontractor Sales to the Government

(Jun 2020) - Alternate I (Nov 2021)

52.203-13 Contractor Code of Business Ethics and Conduct (Nov

2021)

52.204-13 (DEV) System for Award Management-Maintenance (Oct 2018)

(DEVIATION NOV 2025)

52.204-19 Incorporation by Reference of Representations and

Certifications (Dec 2014)

52.204-91 (DEV) Contractor Identification (DEVIATION NOV 2025)

52.209-6 (DEV) Protecting the Government's Interest When

Subcontracting with Contractors Debarred, Suspended, Proposed for Debarment, or Voluntarily Excluded (Jan

2025) (DEVIATION NOV 2025)

52.209-9 (DEV) Updates of Publicly Available Information Regarding

Responsibility Matters (Oct 2018) (DEVIATION NOV

2025)

52.209-10 (DEV) Prohibition on Contracting With Inverted Domestic

Corporations (Nov 2015) (DEVIATION NOV 2025)

15BCTS26Q00000006 Page 26 of 45

Clause Title Fill-ins (if applicable)

52.219-6 (DEV) Notice of Total Small Business Set-Aside (Nov 2020)

(DEVIATION DEC 2025)

52.219-8 (DEV) Utilization of Small Business Concerns (Jan 2025)

(DEVIATION DEC 2025)

52.222-3 (DEV) Convict Labor (June 2003) (DEVIATION DEC 2025)

52.222-19 (DEV) Child Labor-Cooperation with Authorities and Remedies

(Jan 2025) (DEVIATION MAR 2026)

52.222-35 (DEV) Equal Opportunity for Veterans (Jun 2020) (DEVIATION

DEC 2025)

52.222-36 (DEV) Equal Opportunity for Workers with Disabilities (Jun

2020) (DEVIATION DEC 2025)

52.222-37 (DEV) Employment Reports on Veterans (Jun 2020)

(DEVIATION DEC 2025)

52.222-40 (DEV) Notification of Employee Rights Under the National

Labor Relations Act (Dec 2010) (DEVIATION DEC

2025)

52.222-41 (DEV) Service Contract Labor Standards (Aug 2018)

(DEVIATION DEC 2025)

52.222-50 (DEV) Combating Trafficking in Persons (Oct 2025)

(DEVIATION DEC 2025)

52.222-54 (DEV) Employment Eligibility Verification (Jan 2025)

(DEVIATION DEC 2025)

52.222-90 Addressing DEI Discrimination by Federal Contractors

(APR 2026)

52.224-3 Privacy Training (Jan 2017)

52.226-8 Encouraging Contractor Policies To Ban Text

Messaging While Driving (May 2024)

52.232-33 Payment by Electronic Funds Transfer-System for

Award Management (Oct 2018)

52.232-40 Providing Accelerated Payments to Small Business

Subcontractors (Mar 2023)

15BCTS26Q00000006 Page 27 of 45

Clause Title Fill-ins (if applicable)

52.233-3 (DEV) Protest after Award (Aug 1996) (DEVIATION NOV 2025)

52.233-4 (DEV) Applicable Law for Breach of Contract Claim (Oct 2004)

(DEVIATION NOV 2025)

52.240-91 (DEV) Security Prohibitions and Exclusions (DEVIATION NOV

2025)

52.240-93 (DEV) Basic Safeguarding of Covered Contractor Information

Systems (DEVIATION NOV 2025)

52.242-13 Bankruptcy (July 1995)

52.242-15 Stop-Work Order (Aug 1989)

52.252-6 Authorized Deviations in Clauses (Nov 2020) Regulation Name: "FAR provision or clause deviations"

CFR: "Chapter 1"

52.212-4 (DEV) Terms and Conditions-Commercial Products and

Commercial Services (Nov 2023) (DEVIATION NOV

2025)

52.253-1 (DEV) Computer Generated Forms (Jan 1991) (DEVIATION

NOV 2025)

Clauses By Full Text

52.216-18 Ordering (Aug 2020)

(a) Any supplies and services to be furnished under this contract shall be ordered by issuance of delivery orders or task orders by the individuals or activities designated in the Schedule. Such orders may be issued from start of performance period through end of performance period [insert dates].

(b) All delivery orders or task orders are subject to the terms and conditions of this contract. In the event of conflict between a delivery order or task order and this contract, the contract shall control.

(c) A delivery order or task order is considered "issued" when--

(1) If sent by mail (includes transmittal by U.S. mail or private delivery service), the Government deposits the order in the mail;

(2) If sent by fax, the Government transmits the order to the Contractor's fax number; or

(3) If sent electronically, the Government either--

(i) Posts a copy of the delivery order or task order to a Government document access system, and notice is sent to the Contractor; or

15BCTS26Q00000006 Page 28 of 45

(ii) Distributes the delivery order or task order via email to the Contractor's email address.

(d) Orders may be issued by methods other than those enumerated in this clause only if authorized in the contract.

(End of clause)

52.216-19 Order Limitations (Oct 1995)

(a) Minimum order. When the Government requires supplies or services covered by this contract in an amount of less than $1.00 [insert dollar figure or quantity], the Government is not obligated to purchase, nor is the Contractor obligated to furnish, those supplies or services under the contract.

(b) Maximum order. The Contractor is not obligated to honor--

(1) Any order for a single item in excess of the estimated quantities identified on the SF-1449 (Block 21, Quantity) within the current contract performance period [insert dollar figure or quantity];

(2) Any order for a combination of items in excess of the estimated quantities identified on the SF-1449 (Block 21, Quantity) within the current contract performance period [insert dollar figure or quantity]; or

(3) A series of orders from the same ordering office within 30 days that together call for quantities exceeding the limitation in paragraph (b)(1) or (2) of this section.

(c) If this is a requirements contract (i.e., includes the Requirements clause at subsection 52.216-21 of the Federal Acquisition Regulation (FAR)), the Government is not required to order a part of any one requirement from the Contractor if that requirement exceeds the maximum-order limitations in paragraph (b) of this section.

(d) Notwithstanding paragraphs (b) and (c) of this section, the Contractor shall honor any order exceeding the maximum order limitations in paragraph (b), unless that order (or orders) is returned to the ordering office within 7 days after issuance, with written notice stating the Contractor's intent not to ship the item (or items) called for and the reasons. Upon receiving this notice, the Government may acquire the supplies or services from another source.

(End of clause)

52.216-22 (DEV) Indefinite Quantity (Oct 1995) (DEVIATION DEC 2025)

(a) This is an indefinite-quantity contract for the supplies or services specified, and effective for the period stated, in the Schedule. The quantities of supplies and services specified in the Schedule are estimates only and are not purchased by this contract.

(b) Delivery or performance shall be made only as authorized by orders issued in accordance with the Ordering clause.

The Contractor shall furnish to the Government, when and if ordered, the supplies or services specified in the Schedule up to and including the quantity designated in the Schedule as the "maximum." The Government shall order at least the quantity of supplies or services designated in the Schedule as the "minimum."

(c) Except for any limitations on quantities in the Order Limitations clause or in the Schedule, there is no limit on the number of orders that may be issued. The Government may issue orders requiring delivery to multiple destinations or performance at multiple locations.

(d) Any order issued during the ordering period of this contract and not completed within that period shall be completed by the Contractor within the time specified in the order, which may include order options to be exercised after the ordering period of this contract but before the end of the period of performance of the order. The contract shall govern the Contractor's and Government's rights and obligations with respect to that order, including options exercised, to the same extent as if the order were completed during the contract's ordering period; provided, that the Contractor shall not be required to make any deliveries under this contract after the last day of the contract's effective period[insert date].

(End of clause)

15BCTS26Q00000006 Page 29 of 45

52.217-8 Option to Extend Services (Nov 1999)

The Government may require continued performance of any services within the limits and at the rates specified in the contract. These rates may be adjusted only as a result of revisions to prevailing labor rates provided by the Secretary of Labor. The option provision may be exercised more than once, but the total extension of performance hereunder shall not exceed 6 months. The Contracting Officer may exercise the option by written notice to the Contractor within the current performance period [insert the period of time within which the Contracting Officer may exercise the option].

(End of clause)

52.232-18 Availability of Funds (Apr 1984)

Funds are not presently available for this contract. The Government's obligation under this contract is contingent upon the availability of appropriated funds from which payment for contract purposes can be made. No legal liability on the part of the Government for any payment may arise until funds are made available to the Contracting Officer for this contract and until the Contractor receives notice of such availability, to be confirmed in writing by the Contracting Officer.

(End of clause)

52.237-7 (DEV) Indemnification and Medical Liability Insurance (Jan 1997) (DEVIATION NOV 2025)

(a) It is expressly agreed and understood that this is a nonpersonal…