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-FY23-0210: Adult and Older Adult 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:

SECTION I

For existing BHSD-contracted Adult and Older Adult System of Care Providers interested in being added to the QP to provide current contracted services listed on this RFSQ. Offeror shall confirm the following statements:

CATEGORY 1: Prevention and Early Intervention Services

☐ A1: In-Home Outreach Team

☐ A2: New Refugee Prevention and Early Intervention Services

☐ A3: Promotores

☐ A4: Elders' Storytelling

☐ A5: Culturally Appropriate Wellness Centers

☐ A6: Older Adult In-Home Peer Respite

☐ A7: Older Adult Prevention and Early Intervention Services

CATEGORY 2: Outpatient Services

☐ A8: Adult and Older Adult Outpatient Continuum Services ☐ Individual Placement and Support (IPS) | Supported Employment (SE)

☐ A9: Adult and Older Adult Culturally Appropriate Outpatient Continuum Services

☐ A10: Adult and Older Adult Integrated Outpatient Continuum Services - Developmental Disabilities and Autism

☐ A11: Adult and Older Adult California Work Opportunity and Responsibility to Kids (CalWORKs) Outpatient Continuum Services

☐ A12: Adult and Older Adult Outpatient Continuum Services – Justice Involved

☐ A13: Adult and Older Adult Intensive Outpatient Continuum Services – Justice Involved

CATEGORY 3: Full Service Partnership Services

☐ A14: Cross Systems Initiative Full Service Partnership

☐ A15: Forensic, Diversion, and Reintegration Full Service Partnership

☐ AB109

☐ MHSA

☐ A16: Assertive Community Treatment

☐ A17: Forensic Assertive Community Treatment

☐ A18: Assisted Outpatient Treatment

CATEGORY 4: Community Reintegration Services

☐ A19: Forensic, Diversion, and Reintegration Aftercare Services

☐ A20: Post-Release Community Supervision Services

CATEGORY 5: Property Management Services

☐ A21: Master Lease Housing Program for Intensive Services

CATEGORY 6: Substance Use Treatment Services Outpatient Services

☐ A22: Adult and Older Adult Substance Use Treatment Outpatient Continuum Services ☐ ASAM Level 1 ☐ ASAM Level 2.1

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

☐ Attached SOW of the above identified program(s)

Offeror agrees to submit the following documentation for requalification:

SECTION II

If this section is not applicable, continue to Section III.

Indicate your organization’s status:

☐ Offeror does not have an existing contract/agreement with BHSD.

OR

☐ Offeror is an existing contracted BHSD Treatment Facility Service provider interested in providing NEW program service(s) not included in a current contract.

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

a. Select applicable levels of care;

b. Fill in slot and budget amount(s) proposed and initial on each program line.

CATEGORY 1: Prevention and Early Intervention Services

Application for Qualification Indicate Programs as applicable

per Program Response/ Initials

· By Initialing, Offeror indicates services shall be provided in all County regions (North, East, South, Central):

CATEGORY 2: Outpatient Services

Application for Qualification Indicate Programs as applicable

per Program Response/ Initials

☐ A8: Adult and Older Adult Outpatient Continuum Services

☐ Individual Placement and Support (IPS) | Supported Employment (SE)

☐ A13: Adult and Older Adult Intensive Outpatient Continuum Services – Justice Involved

A13:

A13:

CATEGORY 3: Full Service Partnership Services

Application for Qualification Indicate Programs as applicable

per Program Response/ Initials

CATEGORY 4: Community Reintegration Services

Application for Qualification Indicate Programs as applicable

per Program Response/ Initials

☐ A20: Post-Release Community Supervision Services

A20:

A20:

CATEGORY 5: Property Management Services

Application for Qualification Indicate Programs as applicable

per Program Response/ Initials

CATEGORY 6: Substance Use Treatment Services Outpatient Services

Application for Qualification Indicate Programs as applicable

per Program Response/ Initials

☐ A22: Adult and Older Adult Substance Use Treatment Outpatient Continuum Services

☐ ASAM Level 1 ☐ ASAM Level 2.1

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:

Last Revised 10/24/25