Solicitation 15BCTS23Q00000010.pdf
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15BCTS23Q00000010 Page 1 of 69
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
15BCTS23Q00000010
2. CONTRACT NUMBER 3. AWARD/EFFECTIVE
DATE
4. ORDER NUMBER 6. SOLICITATION ISSUE
DATE
04/28/2023
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
05/29/2023 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
(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
010-23
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
15B100CODE15. DELIVER TO
Federal Bureau of Prisons Mid Atlantic Regional Office 302 Sentinel Drive Suite 200 Annapolis Junction, MD 20701
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 NUMBER
17a. CONTRACTOR/
OFFEROR
15B100CODE18a. PAYMENT WILL BE MADE BY
Federal Bureau of Prisons Mid Atlantic Regional Office 302 Sentinel Drive Suite 200 Annapolis Junction, MD 20701
BOP-RSD-CRBCTS-BILL-DC.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: 08/01/2023
Substance Use, Mental Health, Medication Assisted Treatment and Sex Offender Treatment Services in Charlotte, NC 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)
Kia Warner
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
15BCTS23Q00000010 Page 2 of 69
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
15BCTS23Q00000010 Page 3 of 69
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) 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 (Dec 2022) 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) 52.21-603-70 Contracting Officer's Representative (COR) (June 2012) 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) 52.223-22 Public Disclosure of Greenhouse Gas Emissions and Reduction Goals-Representation (Dec 2016) 52.204-24 Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment (Dec 2019) 52.209-7 Information Regarding Responsibility Matters (Oct 2018) 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 (Mar 2023) 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)
15BCTS23Q00000010 Page 4 of 69
Section 2 - Commodity or Services Schedule
SCHEDULE OF SUPPLIES/SERVICES
CONTINUATION SHEET
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0001 Substance Use Disorder Treatment Planning and Follow-up (2001)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0002 Substance Use Disorder Intake Screening (2005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0003 Substance Use Disorder Individual Counseling (2010)
40 Units Guaranteed Minimum; 800 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
40 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0004 Substance Use Disorder Intake Assessment & Report (2011)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0005 Co-occurring Intake Assessment & Report (2012)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0006 Substance Use Disorder Group Counseling (2020)
240 Units Guaranteed Minimum; 4500 Units Estimated Maximum
240 $________ $_________________
15BCTS23Q00000010 Page 5 of 69
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES 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
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0008 MAT – Follow-Up & Report (4004)
1 Unit Guaranteed Minimum; 120 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0009 MAT - Intake Screening (4005)
1 Unit Guaranteed Minimum; 60 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0010 MAT – Administration of Medication (4045)
1 Unit Guaranteed Minimum; 24 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0011 MAT Psychiatric Evaluation & Report (4050)
1 Unit Guaranteed Minimum; 40 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0012 Mental Health Treatment Planning and Follow-up (5001)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
2 $________ $_________________
15BCTS23Q00000010 Page 6 of 69
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0013 Mental Health Intake Screening (5005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0014 Mental Health Intake Assessment & Report (5011)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0015 Psychiatric Evaluation & Report (5030)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0016 Crisis Intervention Evaluation & Report (6000)
1 Unit Guaranteed Minimum; 10 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0017 Mental Health Individual Counseling (6010)
64 Units Guaranteed Minimum; 960 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
64 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0018 Mental Health Relationship and Parenting Counseling (6031)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
15BCTS23Q00000010 Page 7 of 69
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0019 MH - Administration of Medication (6050)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0020 MH - Medication Monitoring & Report (6051)
2 Units Guaranteed Minimum; 240 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0021 Sex Offender Intake Assessment & Report (5012)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0022 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0023 Sex Offender Intake Screening (6005)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Base Period: Date of award - 12 months
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0024 Sex Offender Individual Counseling (6012)
8 Units Guaranteed Minimum; 400 Units Estimated Maximum
8 $________ $_________________
15BCTS23Q00000010 Page 8 of 69
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0025 Substance Use Disorder Treatment Planning and Follow-up (2001)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0026 Substance Use Disorder Intake Screening (2005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0027 Substance Use Disorder Individual Counseling (2010)
40 Units Guaranteed Minimum; 800 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
40 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0028 Substance Use Disorder Intake Assessment & Report (2011)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0029 Co-occurring Intake Assessment & Report (2012)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0030 Substance Use Disorder Group Counseling (2020)
240 Units Guaranteed Minimum; 4500 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 9 of 69
PSC: G004
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0031 Substance Use Disorder Relationship and Parenting Counseling (2030)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0032 MAT – Follow-Up & Report (4004)
1 Unit Guaranteed Minimum; 120 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0033 MAT - Intake Screening (4005)
1 Unit Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0034 MAT – Administration of Medication (4045)
1 Unit Guaranteed Minimum; 24 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0035 MAT Psychiatric Evaluation & Report (4050)
1 Unit Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0036 Mental Health Treatment Planning and Follow-up (5001)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 10 of 69
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0037 Mental Health Intake Screening (5005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0038 Mental Health Intake Assessment & Report (5011)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0039 Psychiatric Evaluation & Report (5030)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0040 Crisis Intervention Evaluation & Report (6000)
1 Unit Guaranteed Minimum; 10 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0041 Mental Health Individual Counseling (6010)
64 Units Guaranteed Minimum; 960 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
64 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0042 Mental Health Relationship and Parenting Counseling (6031)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT
15BCTS23Q00000010 Page 11 of 69
UNIT PRICE AMOUNT
0043 MH - Administration of Medication (6050)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0044 MH - Medication Monitoring & Report (6051)
2 Units Guaranteed Minimum; 240 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0045 Sex Offender Intake Assessment & Report (5012)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0046 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0047 Sex Offender Intake Screening (6005)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0048 Sex Offender Individual Counseling (6012)
8 Units Guaranteed Minimum; 400 Units Estimated Maximum
Option Year 1: Months 13 through 24
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 12 of 69
UNIT PRICE AMOUNT
0049 Substance Use Disorder Treatment Planning and Follow-up (2001)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0050 Substance Use Disorder Intake Screening (2005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0051 Substance Use Disorder Individual Counseling (2010)
40 Units Guaranteed Minimum; 800 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
40 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0052 Substance Use Disorder Intake Assessment & Report (2011)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0053 Co-occurring Intake Assessment & Report (2012)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0054 Substance Use Disorder Group Counseling (2020)
240 Units Guaranteed Minimum; 4500 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 13 of 69
UNIT PRICE AMOUNT
0055 Substance Use Disorder Relationship and Parenting Counseling (2030)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0056 MAT – Follow-Up & Report (4004)
1 Unit Guaranteed Minimum; 120 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0057 MAT - Intake Screening (4005)
1 Unit Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0058 MAT – Administration of Medication (4045)
1 Unit Guaranteed Minimum; 24 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0059 MAT Psychiatric Evaluation & Report (4050)
1 Unit Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0060 Mental Health Treatment Planning and Follow-up (5001)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 14 of 69
UNIT PRICE AMOUNT
0061 Mental Health Intake Screening (5005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0062 Mental Health Intake Assessment & Report (5011)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0063 Psychiatric Evaluation & Report (5030)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0064 Crisis Intervention Evaluation & Report (6000)
1 Unit Guaranteed Minimum; 10 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0065 Mental Health Individual Counseling (6010)
64 Units Guaranteed Minimum; 960 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
64 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0066 Mental Health Relationship and Parenting Counseling (6031)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 15 of 69
UNIT PRICE AMOUNT
0067 MH - Administration of Medication (6050)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0068 MH - Medication Monitoring & Report (6051)
2 Units Guaranteed Minimum; 240 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0069 Sex Offender Intake Assessment & Report (5012)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0070 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0071 Sex Offender Intake Screening (6005)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0072 Sex Offender Individual Counseling (6012)
8 Units Guaranteed Minimum; 400 Units Estimated Maximum
Option Year 2: Months 25 through 36
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 16 of 69
UNIT PRICE AMOUNT
0073 Substance Use Disorder Treatment Planning and Follow-up (2001)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0074 Substance Use Disorder Intake Screening (2005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0075 Substance Use Disorder Individual Counseling (2010)
40 Units Guaranteed Minimum; 800 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
40 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0076 Substance Use Disorder Intake Assessment & Report (2011)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0077 Co-occurring Intake Assessment & Report (2012)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0078 Substance Use Disorder Group Counseling (2020)
240 Units Guaranteed Minimum; 4500 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 17 of 69
UNIT PRICE AMOUNT
0079 Substance Use Disorder Relationship and Parenting Counseling (2030)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0080 MAT – Follow-Up & Report (4004)
1 Unit Guaranteed Minimum; 120 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0081 MAT - Intake Screening (4005)
1 Unit Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0082 MAT – Administration of Medication (4045)
1 Unit Guaranteed Minimum; 24 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0083 MAT Psychiatric Evaluation & Report (4050)
1 Unit Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0084 Mental Health Treatment Planning and Follow-up (5001)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 18 of 69
UNIT PRICE AMOUNT
0085 Mental Health Intake Screening (5005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0086 Mental Health Intake Assessment & Report (5011)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0087 Psychiatric Evaluation & Report (5030)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0088 Crisis Intervention Evaluation & Report (6000)
1 Unit Guaranteed Minimum; 10 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0089 Mental Health Individual Counseling (6010)
64 Units Guaranteed Minimum; 960 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
64 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0090 Mental Health Relationship and Parenting Counseling (6031)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 19 of 69
UNIT PRICE AMOUNT
0091 MH - Administration of Medication (6050)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0092 MH - Medication Monitoring & Report (6051)
2 Units Guaranteed Minimum; 240 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0093 Sex Offender Intake Assessment & Report (5012)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0094 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0095 Sex Offender Intake Screening (6005)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0096 Sex Offender Individual Counseling (6012)
8 Units Guaranteed Minimum; 400 Units Estimated Maximum
Option Year 3: Months 37 through 48
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 20 of 69
UNIT PRICE AMOUNT
0097 Substance Use Disorder Treatment Planning and Follow-up (2001)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0098 Substance Use Disorder Intake Screening (2005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0099 Substance Use Disorder Individual Counseling (2010)
40 Units Guaranteed Minimum; 800 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
40 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0100 Substance Use Disorder Intake Assessment & Report (2011)
20 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0101 Co-occurring Intake Assessment & Report (2012)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0102 Substance Use Disorder Group Counseling (2020)
240 Units Guaranteed Minimum; 4500 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 21 of 69
UNIT PRICE AMOUNT
0103 Substance Use Disorder Relationship and Parenting Counseling (2030)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0104 MAT – Follow-Up & Report (4004)
1 Unit Guaranteed Minimum; 120 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0105 MAT - Intake Screening (4005)
1 Unit Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0106 MAT – Administration of Medication (4045)
1 Unit Guaranteed Minimum; 24 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0107 MAT Psychiatric Evaluation & Report (4050)
1 Unit Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0108 Mental Health Treatment Planning and Follow-up (5001)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 22 of 69
UNIT PRICE AMOUNT
0109 Mental Health Intake Screening (5005)
2 Units Guaranteed Minimum; 40 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0110 Mental Health Intake Assessment & Report (5011)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0111 Psychiatric Evaluation & Report (5030)
2 Units Guaranteed Minimum; 60 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0112 Crisis Intervention Evaluation & Report (6000)
1 Unit Guaranteed Minimum; 10 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0113 Mental Health Individual Counseling (6010)
64 Units Guaranteed Minimum; 960 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
64 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0114 Mental Health Relationship and Parenting Counseling (6031)
2 Units Guaranteed Minimum; 100 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 23 of 69
UNIT PRICE AMOUNT
0115 MH - Administration of Medication (6050)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0116 MH - Medication Monitoring & Report (6051)
2 Units Guaranteed Minimum; 240 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
2 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0117 Sex Offender Intake Assessment & Report (5012)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0118 Sex Offender Treatment Disorder Treatment Planning and Follow-up (6001)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0119 Sex Offender Intake Screening (6005)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0120 Sex Offender Individual Counseling (6012)
8 Units Guaranteed Minimum; 400 Units Estimated Maximum
Option Year 4: Months 49 through 60
Use the Guaranteed Minimum Quantity when developing the total amount.
15BCTS23Q00000010 Page 24 of 69
UNIT PRICE AMOUNT
0121 Substance Use Disorder Treatment Planning and Follow-up (2001)
10 Units Guaranteed Minimum; 30 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0122 Substance Use Disorder Intake Screening (2005)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0123 Substance Use Disorder Individual Counseling (2010)
20 Units Guaranteed Minimum; 400 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
20 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0124 Substance Use Disorder Intake Assessment & Report (2011)
10 Units Guaranteed Minimum; 30 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
10 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0125 Co-occurring Intake Assessment & Report (2012)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0126 Substance Use Disorder Group Counseling (2020)
120 Units Guaranteed Minimum; 2250 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
120 $________ $_________________
15BCTS23Q00000010 Page 25 of 69
UNIT PRICE AMOUNT
0127 Substance Use Disorder Relationship and Parenting Counseling (2030)
1 Unit Guaranteed Minimum; 50 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0128 MAT – Follow-Up & Report (4004)
1 Unit Guaranteed Minimum; 60 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0129 MAT - Intake Screening (4005)
1 Unit Guaranteed Minimum; 30 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0130 MAT – Administration of Medication (4045)
1 Unit Guaranteed Minimum; 12 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0131 MAT Psychiatric Evaluation & Report (4050)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0132 Mental Health Treatment Planning and Follow-up (5001)
1 Unit Guaranteed Minimum; 30 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
1 $________ $_________________
15BCTS23Q00000010 Page 26 of 69
UNIT PRICE AMOUNT
0133 Mental Health Intake Screening (5005)
1 Unit Guaranteed Minimum; 20 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0134 Mental Health Intake Assessment & Report (5011)
1 Unit Guaranteed Minimum; 30 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0135 Psychiatric Evaluation & Report (5030)
1 Unit Guaranteed Minimum; 30 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0136 Crisis Intervention Evaluation & Report (6000)
1 Unit Guaranteed Minimum; 5 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0137 Mental Health Individual Counseling (6010)
32 Units Guaranteed Minimum; 480 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
32 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0138 Mental Health Relationship and Parenting Counseling (6031)
1 Unit Guaranteed Minimum; 50 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
1 $________ $_________________
15BCTS23Q00000010 Page 27 of 69
UNIT PRICE AMOUNT
0139 MH - Administration of Medication (6050)
1 Unit Guaranteed Minimum; 10 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0140 MH - Medication Monitoring & Report (6051)
1 Unit Guaranteed Minimum; 120 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________ $_________________
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
0141 Sex Offender Intake Assessment & Report (5012)
1 Unit Guaranteed Minimum; 10 Units Estimated Maximum
Potential 6 Month Extension
Use the Guaranteed Minimum Quantity when developing the total amount.
PSC: G004
1 $________…
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