2025.453 ATTACHMENT B - APPLICATION BLOCK RFA CHILD WELFARE GRANT PROGRAM.pdf

Child and Welfare Block Grant Program Request for Application Form

(Please print or type. If additional space is needed to complete an answer, use a separate sheet of paper with the attachment number and the letter or number the answer refers to. Include the Legal Agency name on each sheet).

LEGAL Agency Name:

Type (LLC/Sole Prop/etc.):

Address:

City: State: Zip:

Telephone Number:

Fax Number:

Website: Email Address:

Contact Person for this Application:

Title: Phone: Email:

Executive Director, CEO, or Owner:

Title: Phone: Email:

ACTIVE SAMS REGISTRATION: _____________________

UNIQUE IDENTIFIER NUMBER: ____________________________________________________

BLOCK FUNDED SERVICES: Check all services that your agency is applying for:

A. Sibling Visitation B. Paternity Testing / Genetic Testing C. Family Search / Diligent Search Services D. Structured Analysis Family Evaluation Home Studies E. Removal Prevention Services F. Substance Monitoring Services G. Youth Intervention Services

Attachment B

H. Translation and Interpretation Services

I. Answering Service J. Cleaning Service K. Tutoring Service L. Respite Services

Additional Information:

Do you have a current Agreement with Adams County: yes no If yes, please answer the following questions (if multiple, please provide information on a separate attachment) Agreement Number:

Agreement Start Date:

Agreement Expiration Date:

Agreement Services Provided (Ex., Life Skills, Home-Based, Mental Health, etc.):

A. Agency Information

1. Provide a brief description of your agency, and / or organization including total staff size, number of years in operations, mission and history.

2. List any professional, state, or required licenses, and accreditation/certification levels, if any.

3. Is your agency a Medicaid provider?

If not, is your agency qualified to become an authorized provider?

B. Programs / Services to be provided, in the context of this RFA

1. What specific type(s) of service and area of specialization(s) does your agency provide?

a) What service delivery methods and mechanisms would you implement? Include specific methods and techniques you will use for engaging and motivating clients and families.

b) What evidenced-based approaches or promising practices does your agency employ? (Please indicate if you have any specific certifications to accompany these.)

2. Please explain how your agency’s services will address the five Block Services goals of:

a) Focus on the family strengths by directing intensive services that support and strengthen the family and protect the child:

b) Prevent out-of-home placement:

c) Return children in placement to their own home:

d) Unite children with their permanent families:

e) Provide services that protect the child:

3. Do you have experience working in the Child Welfare System, particularly with traumatized children and families? Please describe your agency’s approach to trauma informed care within your practice.

4. Describe how you will be multi-culturally responsive and how you plan to provide services that meet the social, cultural and language needs of clients involved in the Child Welfare System.

C. Collaboration

Providing services for Child Welfare clients involves the ability to advocate and collaborate on behalf of the clients you serve and yourself. This includes collaboration with ACHSD, community-based organizations and other government entities.

1. How do you plan to coordinate services and reporting with Child Welfare Social Case Workers?

2. Will you provide other supportive services through collaborative agreements with other programs/providers? If so, define these services:

3. It is likely that you or your staff will be expected to testify on the witness stand during Court Hearings.

Briefly describe your (their) experience and the qualifications that would qualify you as experts in child welfare or other fields.

D. Report and Accounting Systems

1. ACHSD requires monthly reports with specific information. Briefly describe your methodology and ability to track data and provide these reports on client progress.

2. Describe the accounting system you utilize to provide fiduciary accountability.

E. Target Population

1. Which, if any, Adams County area/neighborhoods do you see as your targeted clientele?

F. Availability Please indicate the hours your services can be provided:

*Availability to provide services evenings and weekends is preferable.

Monday - Friday a.m. to p.m.

Evenings days Hours

Weekends days Hours

Other:

Can services be provided in the client’s home? YES NO

Can you transport a client for services? YES NO

G. Services Outcomes Please provide the following data for clients who have received your services:

1. Average length of stay in treatment:________________________

2. How do you define “successful” treatment in your program?

3. What percentage of clients successfully discharged within the last 12 months from your program?____________________________

H. Sustainability

1. ACHSD does not guarantee a specific number of case referrals and contracts may be terminated at any time. ACHSD values continuity and sustainability of care for clients involved in the child welfare system and desires providers who adopt sustainable business practices to promote fiscal and programmatic efficiencies. Do you receive referrals from other County Department of Human Services Agencies, Court, etc.? If so, please list:

I. Medicaid

1. Are you/your agency currently a Medicaid provider with Colorado Access (Adams County’s RAE)?

a. If so, please provide your PNI number: ___________

b. If not, are you/your agency willing to apply to become a Medicaid provider? _______

2. Please list which services your agency provides that are reimbursable through Medicaid:

3. Are there any Medicaid-eligible reimbursable services that you provide that your agency is currently not billing to

Medicaid (regardless of the reason)? ________ If yes, please list those services and why you/your agency is not billing Medicaid:

4. What, if any, services do you/your agency provide that are not reimbursable through Medicaid?