Appendix A.docx

Santa Clara County –Behavioral Health Services Department RFP-BHS-FYXX-XXXX: RFP Title

APPENDIX A

County of Santa Clara – Behavioral Health Services Department RFSQ-BHS-FY25-0066: Children, Youth, and Family System of Care Services

COVER SHEET

Agency or Name:

Mailing Address:

City, State, and Zip Code:

Telephone Number: Fax Number:

Name & Title of Contact Person:

Telephone Number: Fax Number:

Email Address:

Please complete the information below regarding your organization, then proceed to the appropriate section(s):

· Section I: For current County-Contracted Providers (CCPs) who provide BHSD services who wish to continue their current contracted services.

· Section II: For organizations either without an existing BHSD contract OR for current CCPs interested in expanding by adding new program services not currently under contract.

SECTION I: For Existing BHSD-Contracted Providers Instructions: If your organization would like to be considered for evaluation as a current County-Contracted Provider (CCP) of a program either (1) for which your organization is contracted with BHSD to provide services (keep program the same), (2) to expand current contracted services by adding geographic location(s), please confirm the following by checking all that apply:

☐ Our organization is an existing BHSD-contracted Children, Youth, and Family System of Care service provider, and all currently contracted programs have been identified and selected below.

☐ Our organization is seeking evaluation as an existing CCP for program(s) we are currently contracted to provide. If selected to enter into contract negotiations as part of the QP, our organization would continue providing these services through this RFSQ process.

☐ Our organization is interested in expanding currently contracted services by adding geographic location(s) beyond those currently under contract with BHSD.

Note: If your organization is interested in expanding services by adding new programs not currently under contract with BHSD, please skip to Section II to complete the required information for new services.

CATEGORY 1: CRISIS

☐ A1a: Mobile Response and Stabilization Services* ☐ A1b: Post Crisis Stabilization Services* *Offeror must apply to both programs (Mobile Response and Stabilization Services and Post Crisis Stabilization Services) to be considered responsive.

Geographic Locations Services will be provided Countywide.

CATEGORY 2: FULL SERVICE PARTNERSHIP SERVICES

☐ A2: Youth Full Service Partnership Continuum Geographic Locations Services will be provided Countywide.

☐ A3: Transitional Age Youth Full Service Partnership Continuum

CATEGORY 3: OUTPATIENT SERVICES

☐ A4: School-Based Outpatient School Districts by Region

· Select all the region(s) and specific school district(s) where services are currently provided.

· Use color Highlighting the region(s) and specific school district(s) that your organization is requesting to expand to (new locations).

☐ Central County ☐ Central County ☐ Cambrian ☐ Campbell Union ☐ Campbell Union High ☐ Cupertino Union ☐ Franklin-McKinley ☐ Lakeside Joint ☐ Loma Prieta Joint Union ☐ Los Gatos Union ☐ Los Gatos-Saratoga Joint Union ☐ Luther Burbank ☐ Moreland ☐ Oak Grove Union ☐ San Jose Unified ☐ Santa Clara Unified ☐ Saratoga Union ☐ Santa Clara County Office of Education (SCCOE) ☐ Union

☐ North County ☐ Los Altos ☐ Mountain View- Los Altos High

☐ Fremont Union High ☐ South County ☐ Gilroy Unified ☐ Morgan Hill Unified

☐ A5: Early Psychosis Intervention - Raising Early Awareness and Creating Hope Geographic Locations Services will be provided Countywide.

☐ A6: Outpatient Continuum Geographic Locations

· Select all the region(s) where services are currently provided.

· Use color highlighting to indicate the region(s) that your organization is requesting to expand to (new locations).

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

· South County (Gilroy, Morgan Hill, and the unincorporated area of San Martin)

☐ A7: Specialty Outpatient Continuum

Specialty Populations

· Select all specialty populations that your organization currently serves.

· Use color highlighting to indicate the specialty populations that your organization is requesting to expand services for (new populations).

☐ African American, African Heritage, and Afro-Caribbean, including individuals from African countries, countries of Bahamans, Jamaica, and Haiti.

☐ Native American, including individuals from all federally recognized tribal groups.

☐ Southeast and South Asian, including individuals from Afghanistan, Cambodia, China, Iran, Iraq, India, Pakistan, Philippines, and Vietnam.

☐ Individuals with intellectual/developmental disabilities, including but not limited to Autism Spectrum Disorder, Cognitive Disabilities, and Fetal Alcohol Spectrum Disorder.

Geographic Locations Services will be provided Countywide.

☐ A8: Early Childhood Mental Health Outpatient Continuum Geographic Locations

· Select all the region(s) where services are currently provided.

· Use color highlighting to indicate the region(s) that your organization is requesting to expand to (new locations).

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

· South County (Gilroy, Morgan Hill, and the unincorporated area of San Martin)

☐ A9: Transitional Age Youth Outpatient Continuum

· Select all the region(s) where services are currently provided.

· Use color highlighting to indicate the region(s) that your organization is requesting to expand to (new locations).

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

· South County (Gilroy, Morgan Hill, and the unincorporated area of San Martin)

☐ A10: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Outpatient Continuum Geographic Locations Services will be provided Countywide.

☐ A11: Cross-Systems Child and Youth Outpatient Continuum (formerly Katie A. Intensive Services)

CATEGORY 4: PREVENTION AND EARLY INTERVENTION

☐ A12: School-Based Early Intervention School Districts by Region

· Select all the region(s) and specific school district(s) where services are currently provided.

· Use color highlighting to indicate the region(s) and specific school district(s) that your organization is requesting to expand to (new locations).

☐ Central County

· Cambrian

· Campbell Union

· Campbell Union High

· Cupertino Union

· Franklin-McKinley

· Lakeside Joint

· Loma Prieta Joint Union

· Los Gatos Union

· Los Gatos-Saratoga Joint Union

· Luther Burbank

· Moreland

· Oak Grove Union

· San Jose Unified

· Santa Clara Unified

· Saratoga Union

· Santa Clara County Office of Education (SCCOE)

· Union ☐ East County

· Alum Rock Union

· Berryessa Union

· East Side Union High

· Evergreen Elementary

· Milpitas Unified

· Mount Pleasant Elementary

· Orchard ☐ North County

· Los Altos

· Mountain View-Los Altos High

· Mountain View-Whisman

· Palo Alto Unified

· Sunnyvale Elementary

· Fremont Union High ☐ South County

· Gilroy Unified

· Morgan Hill Unified

☐ A13: Community Youth Wellness Center - Peer Support and Engagement Program Geographic Locations Select where services would be provided.

☐ allcove Palo Alto ☐ Downtown Youth Wellness Center – San Jose

CATEGORY 5: BEHAVIORAL HEALTH PLACEMENT SUPPORT SERVICES

☐ A14: Therapeutic Behavioral Services Geographic Locations Services will be provided Countywide.

☐ A15: Therapeutic Behavioral Services for Youth with Intellectual Disabilities or Developmental Delay

CATEGORY 6: RESIDENTIAL

☐ A16: Short-Term Residential Therapeutic Program

CATEGORY 7: SUBSTANCE USE TREATMENT SERVICES

☐ A18: Youth Outpatient Substance Use Treatment Services Program Geographic Locations

· Select all the region(s) where services are currently provided.

· Use color highlighting to indicate the region(s) that your organization is requesting to expand to (new locations).

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A19: Youth Residential Substance Use Treatment Services Program

Offeror agrees to the following (must agree and check all items):

☐ The organization agrees to the Scope of Work provided by the County for the respective program as included in the RFSQ attachments.

Offeror agrees to submit the following documentation to be considered for the Current CCPs Evaluation Process outlined on RFSQ Section I.A.4:

☐ Submission of the organization’s Financial Stability documentation, as required in RFSQ Section IV.K.1.

☐ Information on all Corrective Action Plans (CAPs) and/or Performance Improvement Plans (PIPs) from the past five (5) years, specifically related to programs within BHSD (maximum three [3] pages per program, not cumulatively across programs).

☐ Staffing information related to the agency’s current program or similar services (maximum two [2] pages per program, not cumulatively across programs).

SECTION II: For Providers without an Existing BHSD Contract or for Providers Expanding Services Instructions: If your organization does not have an existing contract with BHSD contract for the services in this RFSQ for the Children, Youth, and Family System of Care, or if you are an existing provider interested in offering new program services not currently included in your contract, please complete this section. If not applicable, proceed to Section III.

Indicate your organization’s status:

☐ Our organization does not have an existing contract with BHSD for the services selected below (New Provider).

OR

☐ Our organization has an existing BHSD contract and is interested in providing new program service(s) not included in our current contract (Expanding Services).

Indicate your organization’s interest by completing all applicable program lines below.

CATEGORY 1: CRISIS

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/ Initials

☐ A1a: Mobile Response and Stabilization Services*

☐ A1b: Post Crisis Stabilization Services*

*Offeror must apply to both programs (Mobile Response and Stabilization Services and Post Crisis Stabilization Services) to be considered responsive.

Geographic and Clinic Locations Services will be provided Countywide.

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

CATEGORY 2: FULL SERVICE PARTNERSHIP SERVICES

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A2: Youth Full Service Partnership Continuum

Geographic and Clinic Locations

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A3: Transitional Age Youth Full Service Partnership Continuum

Geographic and Clinic Locations

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

CATEGORY 3: OUTPATIENT SERVICES

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A4: School-Based Outpatient

School Districts by Region Select the region(s) and specific school district(s) where services would be provided.

☐ Central County ☐ Central County ☐ Cambrian ☐ Campbell Union ☐ Campbell Union High ☐ Cupertino Union ☐ Franklin-McKinley ☐ Lakeside Joint ☐ Loma Prieta Joint Union ☐ Los Gatos Union ☐ Los Gatos-Saratoga Joint Union ☐ Luther Burbank ☐ Moreland ☐ Oak Grove Union ☐ San Jose Unified ☐ Santa Clara Unified ☐ Saratoga Union ☐ Santa Clara County Office of Education (SCCOE) ☐ Union

☐ North County ☐ Los Altos ☐ Mountain View- Los Altos High

☐ Fremont Union High ☐ South County ☐ Gilroy Unified ☐ Morgan Hill Unified

CATEGORY 3: OUTPATIENT SERVICES

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A5: Early Psychosis Intervention - Raising Early Awareness and Creating Hope

☐ A6: Outpatient Continuum

Geographic Locations Select where services would be provided.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A7: Specialty Outpatient Continuum

Specialty Populations Select all specialty populations your organization will serve.

☐ African American, African Heritage, and Afro-Caribbean, including individuals from African countries, countries of Bahamans, Jamaica, and Haiti.

☐ Native American, including individuals from all federally recognized tribal groups.

☐ Southeast and South Asian, including individuals from Afghanistan, Cambodia, China, Iran, Iraq, India, Pakistan, Philippines, and Vietnam.

☐ Individuals with intellectual/developmental disabilities, including but not limited to Autism Spectrum Disorder, Cognitive Disabilities, and Fetal Alcohol Spectrum Disorder.

Geographic Locations Services will be provided Countywide.

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

CATEGORY 3: OUTPATIENT SERVICES

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A8: Early Childhood Mental Health Outpatient Continuum

Geographic Locations

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A9: Transitional Age Youth Outpatient Continuum

Geographic Locations

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A10: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Outpatient Continuum

Geographic Locations

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A11: Cross-Systems Child and Youth Outpatient Continuum (formerly Katie A. Intensive Services)

Geographic and Clinic Locations

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

· South County (Gilroy, Morgan Hill, and the unincorporated area of San Martin)

CATEGORY 4: PREVENTION AND EARLY INTERVENTION

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A12: School-Based Early Intervention

School Districts by Region Select the region(s) and specific school district(s) where services would be provided.

☐ Central County

· Cambrian

· Campbell Union

· Campbell Union High

· Cupertino Union

· Franklin-McKinley

· Lakeside Joint

· Loma Prieta Joint Union

· Los Gatos Union

· Los Gatos-Saratoga Joint Union

· Luther Burbank

· Moreland

· Oak Grove Union

· San Jose Unified

· Santa Clara Unified

· Saratoga Union

· Santa Clara County Office of Education (SCCOE)

· Union ☐ East County

· Alum Rock Union

· Berryessa Union

· East Side Union High

· Evergreen Elementary

· Milpitas Unified

· Mount Pleasant Elementary

· Orchard ☐ North County

· Los Altos

· Mountain View-Los Altos High

· Mountain View-Whisman

· Palo Alto Unified

· Sunnyvale Elementary

· Fremont Union High ☐ South County

· Gilroy Unified

· Morgan Hill Unified

CATEGORY 4: PREVENTION AND EARLY INTERVENTION

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A13: Community Youth Wellness Center - Peer Support and Engagement Program

Geographic Locations

☐ allcove Palo Alto ☐ Downtown Youth Wellness Center – San Jose

CATEGORY 5: BEHAVIORAL HEALTH PLACEMENT SUPPORT SERVICES

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A14: Therapeutic Behavioral Services

Geographic Locations

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A15: Therapeutic Behavioral Services for Youth with Intellectual Disabilities or Developmental Delay

Geographic Locations

Select all geographic areas where your clinics will be physically located.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (Alviso, San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

CATEGORY 6: RESIDENTIAL

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A16: Short-Term Residential Therapeutic Program*

☐ A17: Youth Crisis Residential*

*Programs must be located in Santa Clara County or within a 90-mile radius and have the necessary licensing before contract execution.

CATEGORY 7: SUBSTANCE USE TREATMENT SERVICES

Application for Qualification Indicate Programs as applicable Desired Slots per Program Maximum Financial Obligation per Program Response/

☐ A18: Youth Outpatient Substance Use Treatment Services Program

Geographic Locations

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

· East County (San Jose [Foothills, Berryessa] and Northeast San Jose/Milpitas areas)

☐ A19: Youth Residential Substance Use Treatment Services Program*

*Program must be located in Santa Clara County or within a 90-mile radius and have the necessary licensing before contract execution.

Select where services would be provided.

· North County (Palo Alto, Los Altos and Los Altos Hills, Mountain View, and Sunnyvale)

· Central County (San Jose, Cupertino, Santa Clara, Los Gatos, Monte Sereno, Saratoga, and Campbell)

SECTION III

Offeror understands, agrees, and warrants:

A. That Offeror has carefully read and fully understands the information that was provided by the County to serve as the basis for submission of this response;

B. That Offeror has the capability to successfully undertake and complete the responsibilities and obligations of the response being submitted;

C. That all information contained in the response is true and correct to the best of Offeror’s knowledge;

D. That Offeror signed a non-collusion affidavit herewith attached with the response;

E. That Offeror did not receive unauthorized information from any County staff or consultant during the response period except as provided for in the RFSQ packet, addenda thereto, or Periscope Q&A timeframe;

F. That by submission of this response, the Offeror acknowledges that the County has the right to make any inquiry it deems appropriate to substantiate or supplement information supplied by the Offeror, and Offeror hereby grants the County permission to make said inquiries, and to provide any and all requested documentation in a timely manner; and

G. That Offeror offers and agrees to furnish the goods and services specified in the response.

No response shall be accepted which has not been signed in ink in the appropriate space below.

I hereby certify that I am an authorized representative of the above agency and to the best of my knowledge and belief that:

The data in this response is true and accurate; the Offeror has investigated all aspects of the RFSQ; the Offeror is aware of the applicable facts pertaining to the RFSQ process, procedures, and requirements; the Offeror has read and understands the RFSQ; the Offeror has the capability to successfully undertake and complete the responsibilities and obligations of their response being submitted; the agency will be able to meet all of the minimum response requirements as specified in this RFSQ; and the Offeror will comply with the necessary certifications and assurances if a contract is awarded.

This shall constitute a warranty, the falsity of which entitles the County to pursue any remedy authorized by law, including the right to declare any contract made as a result thereof to be void.

By signing below, the submission of a response shall be deemed a representation and certification by the Offeror that it has investigated all aspects of the RFSQ; that it is aware of the applicable facts pertaining to the RFSQ process, its procedures and requirements; and that it has read and understands the RFSQ. No request for modification of the response shall be considered after its submission on the grounds that the Offeror was not fully informed as to any fact or condition.

1. If Offeror is an INDIVIDUAL, sign here:

Date

Offeror’s Signature

Offeror’s Name and Title (Type or Print)

1. If Offeror is a CORPORATION, the duly authorized officer(s) shall sign here:

The undersigned certify that they are respectively:

and

Title

Title of the CORPORATION named below; that they are designated to sign this response cost form by resolution or by the Secretary of State's certificate of authorization, for and on behalf of the below named CORPORATION, and that they are authorized to execute same for and on behalf of said CORPORATION.

Corporation Name (Type or Print)

By:

Date:

Title:

By:

Date:

Title: