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Ayuda, Inc.
aooy- a~7a 2~ PROFESSIONAL SERVICES AGREEMENT BETWEEN THE CITY OF MIAMI BEACH, FLORIDA ~~ ~~~' ~ J F~- [;. 1~3 AND AYUDA, INC. ~~ i ~J, ,;i ,.~; .. J F-~C~ FOR YOUTH SERVICES RELATED TO THE CITY'S SERVICE PARTNERSHIP INITIATIVE THIS AGREEMENT made and entered into this 1st day of August, 2009, by and between the CITY OF MIAMI BEACH, FLORIDA (hereinafter referred to as City), having its principal offices at 1700 Convention Center Drive, Miami Beach, Florida, 33139, and Ayuda, Inc., a Florida Corporation, (hereinafter referred to as Contractor), whose address is 13899 Biscayne Blvd. Suite 123, North Miami Beach FI, 33181. SECTION 1 1.1 DEFINITIONS Agreement: This Agreement between the City and Contractor, and any exhibits and/or attachments hereto. City Manager: The Chief Administrative, Officer of the City. Contractor: For the purposes of this Agreement, Contractor shall be deemed to be an independent contractor, and not an agent or employee of the City. Services: All services, work and actions by the Contractor performed pursuant to or undertaken under this Agreement, as described in Section 2 and Exhibit "A" hereto. Fee (Compensation): Amount paid to the Contractor to cover the costs of the Services. Risk Manager: The Risk Manager of the City, with offices at 1700 Convention Center Drive, Third Floor, Miami Beach, Florida 33139, telephone number (305) 673-7000, Ext. 6435, and fax number (305) 673-7023. 1 SECTION 2 SCOPE OF WORK (SERVICES) The Contractor will provide intake and assessment services for up to one hundred and fifty (150) youth and their families in accordance with The Children's Trust Miami Beach Service Partnership Grant, dated August 1, 2009. The scope of work to be performed by Contractor is further detailed in Exhibit "A," entitled "Scope of Services." The Contractor shall report to the City of Miami Beach, Neighborhood Services Department, Office of Community Services, Division Director. SECTION 3 COMPENSATION 3.1 FIXED FEE Contractor shall be compensated for the Services, as set forth in Section 2 and Exhibit "A", as follows: (a) Provision of intake and assessment services for up to one hundred fifty (150) youth .and their families at One Hundred Forty Dollars ($140) per each intake, for a maximum not to exceed Twenty-One Thousand Dollars ($21,000). Contractor's compensation shall be further subject to and conditioned upon all or any portion of the Services to be provided herein being allowable and within the Scope of Services delineated in Exhibit "A". Notwithstanding the preceding, Contractor's total compensation during the term of this Agreement shall not exceed the maximum allowable sum of Twenty-One Thousand Dollars ($21,000). 3.2 INVOICING Contractor shall submit monthly invoices, a Monthly Progress Report, and accompanying Monthly Status Report, as set forth in Exhibit "B", which includes an itemized, detailed description of the Services, or portions thereof, provided (including the clients served) and cost(s) for same. Invoices and supporting documentation shall be submitted to Maria Ruiz, Division Director, Office of Community Services, 1700 Convention Center Drive, Miami Beach, Florida, 33139. 3.3 METHOD OF PAYMENT Payments shall be made within thirty (30) days of the date of invoice, in a manner satisfactory to and as approved and received by the City Manager and/or his designee, who shall be the Division Director, Office of Community Services. 2 SECTION 4 GENERAL PROVISIONS 4.1 RESPONSIBILITY OF THE CONTRACTOR With respect to the performance of the Services, the Contractor shall exercise that degree of skill, care, efficiency and diligence normally exercised by recognized professionals with respect to the performance of comparable services. In its performance of the Services, the Contractor shall comply with all applicable laws, ordinances, and regulations of the City, Miami-Dade County, the State of Florida, and the federal government, as applicable. 4.2 PUBLIC ENTITY CRIMES A State of Florida Form PUR 7068, Sworn Statement under Section 287.133(3)(a) Florida Statute on Public Entity Crimes shall be filed with the City's Procurement Division, prior to commencement of the Services herein. 4.3 DURATION AND EXTENT OF AGREEMENT (TERM) The term of this Agreement shall commence upon execution of this Agreement by all parties hereto, and shall terminate on July 31, 2010. 4.4 TIME OF COMPLETION The Services to be rendered by the Contractor shall be commenced upon receipt of a written Notice to Proceed from the City subsequent to execution of the Agreement by the parties, and shall be completed no later than July 31, 2010. 4.5 INDEMNIFICATION Contractor agrees to indemnify and hold harmless the City of Miami Beach and its officers, employees and agents, from and against any and all actions, claims, liabilities, losses, and expenses, including, but not limited to, attorneys' fees, for personal, economic or bodily injury, wrongful death, loss of or damage to property, at law or in equity, which may arise or be alleged to have arisen from the negligent acts, errors, omissions or other wrongful conduct of the Contractor, its employees, agents, sub-consultants, or any other person or entity acting under Consultant's control, in connection with the Contractor's performance of the Services pursuant to this Agreement; and to that extent, the Contractor shall pay all such claims and losses and shall pay all such costs and judgments which may issue from any lawsuit arising from such claims and losses, and shall pay all costs and attorneys' fees expended by the City in the defense of such claims and losses, including appeals. The Contractor's obligation under this Subsection shall not include the obligation to 3 indemnify the City of Miami Beach and its officers, employees and agents, from and against any actions or claims which arise or are alleged to have arisen from negligent acts or omissions or other wrongful conduct of the City and its officers, employees and agents. The parties each agree to give the other party prompt notice of any claim coming to its knowledge that in any way directly or indirectly affects the other party. 4.6 TERMINATION. SUSPENSION AND SANCTIONS 4.6.1 Termination for Cause If the Contractor shall fail to fulfill in a timely manner, or otherwise violate any of the covenants, agreements, or stipulations material to this Agreement, the City shall thereupon have the right to terminate the Services then remaining to be performed. Prior to exercising its option to terminate for cause, the City shall notify the Contractor of its violation of the particular terms of this Agreement and shall grant Contractor seven (7) days to cure such default. If such default remains uncured after seven (7) days, the City, upon three (3) days' notice to Contractor, may terminate this Agreement and the City shall be fully discharged from any and all liabilities, duties and terms arising out of/or by virtue of this Agreement. Notwithstanding the above, the Contractor shall not be relieved of liability to the City for damages sustained by the City by any breach of the Agreement by the Contractor. The City, at its sole option and discretion, shall additionally be entitled to bring any and all legal/equitable actions that it deems to be in its best interest in order to enforce the City's right and remedies against the defaulting party. The City shall be entitled to recover all costs of such actions, including reasonable attorneys' fees. To the extent allowed by law, the defaulting party waives its right to jury trial and its right to bring permissive counter claims against the City in any such action. 4.6.2 Termination for Convenience of City NOTWITHSTANDING SECTION 4.6.1, THE CITY MAY ALSO, FOR ITS CONVENIENCE AND WITHOUT CAUSE, TERMINATE THIS AGREEMENT AT ANY TIME DURING THE TERM HEREOF BY GIVING WRITTEN NOTICE TO CONSULTANT OF SUCH TERMINATION, WHICH SHALL BECOME EFFECTIVE SEVEN (7) DAYS FOLLOWING RECEIPT BY THE CONSULTANT OF THE WRITTEN TERMINATION NOTICE. IN THAT EVENT, ANY FINISHED OR UNFINISHED DOCUMENTS AND OTHER MATERIALS PREPARED AND OR OTHERWISE COMPILED BY CONSULTANT PURSUANT TO ITS PROVISION OF THE SERVICES CONTEMPLATED IN SECTION 2 AND IN EXHIBIT "A", SHALL BE 4 PROMPTLY ASSEMBLED AND DELIVERED TO THE CITY, AT CONSULTANT'S SOLE COST AND EXPENSE. IF THE AGREEMENT IS TERMINATED BY THE CITY AS PROVIDED IN THIS SUBSECTION, CONSULTANT SHALL BE PAID FOR ANY SERVICES SATISFACTORILY PERFORMED, AS DETERMINED BY THE CITY AT ITS SOLE DISCERTION, UP TO THE DATE OF TERMINATION; PROVIDED, HOWEVER, THAT AS A CONDITION PRECEDENT TO SUCH PAYMENT, CONSULTANT SHALL HAVE DELIVERED ANY AND ALL DOCUMENTS, MATERIALS, ETC, TO CITY, AS REQUIRED HEREIN. 4.6.3 Termination for Insolvency The City also reserves the right to terminate the remaining Services to be performed in the event the Contractor is placed either in voluntary or involuntary bankruptcy or makes an assignment for the benefit of creditors. In such event, the right and obligations for the parties shall be the same as provided for in Section 4.6.2. 4.6.4 Sanctions for Noncompliance with Nondiscrimination Provisions In the event of the Contractor's noncompliance with the nondiscrimination provisions of this Agreement, as applicable, the City shall impose such sanctions as the City or the State of Florida may determine to be appropriate, including but not limited to, withholding of payments to the Contractor under the Agreement until the Contractor complies and/or cancellation, termination or suspension of the Services and/or the Agreement. In the event the City cancels or terminates the Services and/or the Agreement pursuant to this Subsection the rights and obligations of the parties shall be the same as provided in Section 4.6.2. 4.7 CHANGES AND ADDITIONS Any changes and additions to the terms of this Agreement shall be by a written amendment, signed by the duly authorized representatives of the City and Contractor. No alteration, change, or modification of the terms of this Agreement shall be valid unless amended in writing, signed by the parties hereto, and approved by the City. 4.8 OWNERSHIP OF DOCUMENTS Any changes and additions to the terms of this Agreement shall be by a written amendment, signed by the duly authorized representatives of the City and Contractor. No alteration, change, or modification of the terms of this Agreement shall be valid unless amended in writing, signed by the parties hereto, and approved by the City. 5 4.9 AUDIT AND INSPECTIONS Upon 24-hour's written notice, the City Manager (on behalf of the City) and/or such authorized representatives as the City Manager may deem to act on the City's behalf, may, during Contractor's normal business hours, audit, examine and make audits of all contracts, invoices, materials, payrolls, records of personnel, conditions of employment, and any and all other data and/or records and/or documents relating to all matters covered by this Agreement. Contractor shall maintain any and all such records, as necessary to document compliance with the provisions of this Agreement. 4.10 ACCESS TO RECORDS Contractor agrees to allow access during normal business hours to all records including, without limitation, Contractor's financial records, to the City and/or its authorized representatives, and agrees to provide such assistance as may be necessary to facilitate audit by the City and/or its representatives, when and as the City Manager, in his sole and reasonable discretion, may deem necessary to ensure compliance with the provisions of this Agreement including, without limitation, as they pertain to any financial audits (with applicable accounting and financial standards). Contractor shall allow access during normal business hours to any and all records, forms, files, and documents which have been generated in performance of this Agreement, by the City and/or its authorized representatives. 4.11 INSURANCE REQUIREMENTS The Contractor shall not commence any work and/or Services pursuant to this Agreement until all insurance required under this Section has been obtained and such insurance has been reviewed and approved by the City's Risk Manager. Contractor shall maintain and carry in full force during the term of this Agreement the following insurance: 1. Contractor General Liability, in the amount of $1,000,000. 2. Contractor Professional Liability, in the amount of $200,000. 3. Workers Compensation & Employers Liability, as required pursuant to Florida Statutes. All insurance required hereunder must be furnished by insurance companies authorized to do business in the State of Florida. Original certificates of insurance for the above coverage must be submitted to the City's Risk Manager at the Office of the Risk Manager of the City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139. 6 The Contractor is solely responsible for obtaining and submitting all insurance certificates for its sub-contractors. All insurance policies must be issued by companies authorized to do business under the laws of the State of Florida. The companies must be rated no less than "B+" as to management and not less than "Class VI" as to strength by the latest edition of Best's Insurance Guide, published by A.M. Best Company, Oldwick, New Jersey, or its equivalent. Compliance with the foregoing requirements shall not relieve the Contractor of the liabilities and obligations under this Section or under any other portion of this Agreement, and the City shall have the right to obtain from the Contractor specimen copies of the insurance policies in the event that submitted certificates of insurance are inadequate to ascertain compliance with required overage. All of Contractor's certificates, as required in this Section 4.11, shall contain endorsements providing that written notice shall be given to the City at least thirty (30) days prior to termination, cancellation or reduction in coverage in the policy. The Contractor shall not commence any work and/or Services pursuant to this Agreement until the City's Risk Manager has received, reviewed and approved, in writing, certificates of insurance showing that the requirements of this Section (in its entirety) have been met and provided for. 4.12 ASSIGNMENT, TRANSFEROR SUBCONTRACTING The Contractor shall not subcontract, assign, or transfer any work under this Agreement without the prior written consent of the City Manager which consent, if granted at all, shall be at the Manager's sole and absolute discretion. 4.13 SUB-CONTRACTORS The Contractor shall be liable for Contractor's services, responsibilities and liabilities under this Agreement, and the services, responsibilities and liabilities of sub-contractors, and any other person or entity acting under the direction or control of Contractor. When the term "Contractor" is used in this Agreement, it shall be deemed to include any sub-contractors and any other person or entity acting under the direction or control of Contractor. All sub-contractors must be approved, in writing by the City Manager, or his designee, prior to their engagement by Contractor (which approval, if granted at all, shall be at the Manager's sole discretion and judgment). 4.14 EQUAL EMPLOYMENT OPPORTUNITY In connection with the performance of this Agreement, the Contractor shall not discriminate against any employee or applicant for employment because of race, color, religion, ancestry, sex, age, and national origin, place of birth, marital 7 status, or physical handicap. The Contractor shall take affirmative action to ensure that applicants are employed and that employees are treated during their employment without regard to their race, color, religion, ancestry, sex, age, national origin, place of birth, marital status, disability, or sexual orientation, as applicable. 4.15 NO CONFLICT OF INTEREST The Contractor agrees to adhere to and be governed by the Metropolitan Miami-Dade County Conflict of Interest Ordinance, as same may be amended from time to time; and by City of Miami Beach Code, as same may be amended from time to time. The Contractor covenants that it presently has no interest and shall not acquire any interest, direct or indirectly which should conflict in any manner or degree with the performance of the Services. The Contractor further covenants that in the performance of this Agreement, no person having any such interest shall knowingly be employed by the Consultant. No member of or delegate to the Congress of the United States shall be admitted to any share or part of this Agreement or to any benefits arising there from. 4.16 PATENT RIGHTS; COPYRIGHTS; CONFIDENTIAL FINDINGS Any patentable result arising out of this Agreement, as well as all information, design specifications, processes, data and findings, shall be made available in perpetuity to the City, for public use. No reports, other documents, articles or devices produced in whole or in part under this Agreement shall be the subject of any application for copyright or patent by or on behalf of the Contractor or its employees or subcontractors. 4.17 NOTICES All notices and communications relating to the day-to-day activities shall be exchanged between a project manager appointed by the Contractor and the program coordinator designated by the City Manager, who shall be Neighborhood Services Department, Office of Community Services, Division Director. The Contractor's project manager shall be designated following execution of this Agreement by the parties and prior to commencement of the Services. All other notices and communications in writing required or permitted hereunder may be delivered personally to the representatives of the Contractor and the City listed below or may be mailed by registered mail. Until changed by notice in writing, all such notices and communications shall be addressed as follows: 8 TO CONTRACTOR: Ayuda, Inc. Attn: Luis DeJesus, Executive Director 13899 Biscayne -Blvd. Suite 123, North Miami Beach FI, 33181 (305) 864-6885 TO CITY: City of Miami Beach Office of Community Services Attn: Maria L. Ruiz, Director 1700 Convention Center Drive Miami Beach, Florida 33139 (305) 673-7491 4.18 LITIGATION JURISDICTIONNENUE This Agreement shall be governed by, and construed in accordance with, the laws of the State of Florida, both substantive and remedial, without regard to principles of conflict of laws. The exclusive venue for any litigation arising out of the Agreement shall be Miami-Dade County, Florida, if in State court, and the U.S. District Court, Southern District of Florida, if in federal court. BY ENTERING INTO THIS AGREEMENT, CONTRACTOR AND CITY EXPRESSLY WAIVE ANY RIGHTS EITHER PARTY MAY HAVE TO A TRIAL BY JURY OR ANY CIVIL LITIGATION RELATED TO, OR ARISING OUT OF, THIS AGREEMENT. 4.19 ENTIRETY OF AGREEMENT This writing and any exhibits and/or attachments incorporated (and/or otherwise referenced for incorporation) herein embody the entire Agreement and understanding between the parties hereto, and there are no other agreements and understandings, oral or written, with reference to the subject matter hereof that are not merged herein and superseded hereby. 4.20 LIMITATION OF CITY'S LIABILITY The City desires to enter into this Agreement only if in so doing the City can place a limit on the City's liability for any cause of action for money damages due to an alleged breach by the City of this Agreement, so that its liability for any such breach never exceeds the sum of $1,000. Contractor hereby expresses its willingness to enter into this Agreement with Consultant's recovery from the City for any damage action for breach of contract to be limited to a maximum amount of $1,000. 9 Accordingly, and notwithstanding any other term or condition of this Agreement, Contractor hereby agrees that the City shall not be liable to the Contractor for damages in an amount in excess of $1,000 for any action or claim for breach of contract arising out of the performance or non-performance of any obligations imposed upon the City by this Agreement. Nothing contained in this paragraph or elsewhere in this Agreement is in any way intended to be a waiver of the limitation placed upon the City's liability as set forth in Section 768.28, Florida Statutes. [REMAINDER OF THIS PAGE LEFT INTENTIONALLY BLANK] 10 IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their appropriate officials, as of the date first entered above. FOR CITY: CITY OF MIAMI BEACH, FLORIDA ATTEST: X~ City Clerk Mayor FOR CONTRACTOR: ATTEST: Corporate Seal Ayuda, Inc., A Florida Corporation APPROVED AS TO FORM & LANGUAGE .--~ FOR ~CUTION . q 14 ~~ Date 11 Print Name EXHIBIT "A" "SCOPE OF SERVICES" The Contractor agrees to provide the following services to youth referred to the Success University program: _..._._...._.._ ~ __ ............_..._.._~_ ~ ____~_,.._.._._.__.__._ ~ ~ ~~ ..~. _ _~_ ~ ___ ~.__._............_...._._..__________W___._-_________ ................ . Service Documentation of Service Intake & Assessment ~ Completed Success University Intake & Assessment :Form (attached); Copy of completed Referral Form(s) (attached); Documentation of service provided on Community OS Software Related Definitions: Intake & Assessment - An intake and assessment documents the natural supports and needs of the client and his/her family. The intake and assessment form must be completed accurately and completely and submitted to the City, where the client is assigned a number in The Children's Trust Data Tracker system. Referrals -Referrals include the identification of a specific client need and the subsequent identification of a community based resource to address the need. Referrals must be provided for all service needs recognized in the intake and assessment or client-initiated requests. These referrals must be documented using the Miami Beach Service Partnership Referral Form with copies provided to the client and City. Services will be deemed as provided when the following documentation is provided within the noted timeframes: Service Deliverables Service Intake & Assessment Unit of Service ... 1 for .each of up 150 youth Service Location to .Client Home Timeframe All eligible intakes will be completed within thirty (30) days of receipt of appointment Failure to meet contracted service units within the allocated timeframe may result in the City subsequently reducing the Contractor's service level and allocated funding accordingly. 12 If the Contractor is unable to fulfill the contracted service level within the allocated timeframe for each service component, the City reserves the right to reduce service levels accordingly across the funded service spectrum. If the Contractor is unable to fulfill the contracted service level and the City subsequently reduces service and funding levels, the City reserves the right to select another vendor to fulfill the remaining service units. The City will select the alternate vendor at its sole discretion. Reporting Requirements The Contractor will provide the City with a Monthly Progress Report and reimbursement request utilizing the City's Reporting and Reimbursement Forms (attached) by the third (3rd) of the following month. In the event that the third of the month lands on a Saturday, Sunday or holiday, the report must be submitted the following business day. Monthly reports and reimbursement requests will be submitted via any of the following methods: • Electronic mail • Facsimile • Standard mail • Hand delivery Monthly reports will not be considered acceptable unless the following is met: • Forms are completely and accurately filled • Necessary back-up materials are included (client documentation, expense receipts, time logs, etc.) • Reports bear the signature of the person submitting the report on behalf of the Contractor The City will document Contractor service level data and monthly reports via Active Strategy software for inclusion in the monthly report to the Miami Beach Governing Board as well as the City's website. The failure to submit required monthly reports and invoices in a timely manner for two consecutive months will result in the forfeiture of one (1 %) percent of the combined billed total for the two months in question. These forfeited funds will be used exclusively for client incentive materials as approved by the Miami Beach Service Partnership Governing Board. These forfeited funds will be submitted to the City by the Contractor via check within 30 days. 13 Partner Performance Ratings The Contractor agrees that its Partner Performance Rating, the score awarded for performance on the following measures, will be posted on the City's website: • Timely and accurate submission of monthly progress report • Timely and accurate submissions of monthly financial reports (reimbursement requests) • Delivery of contracted service units • Promotion of the Miami Beach Service Partnership • Attendance at Miami Beach Service Partnership Governing Board and related committee(s) meetings Ratings will be given for each performance measure based on the following: Performance Measure Timely and accurate submission of month.~.Y.._progress _re.P...~rt ................................................................................... Timely and accurate submissions of monthly financial reports (reimbursement requests) Delivery of contracted service units Promotion of the Miami Beach Service Partnership Attendance at Miami Partnership Governing committee(s) meetings Ratin4 Rationale & Score - "0" for failing to submit on time -...." 20"..fo.r...submittin.g...o.n.._time ................................................................... - "0" for failing to submit accurate report with back-up material on time - "20" for submitting accurate report on time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Possible score of 0 to 20 based upon completion of monthly projected service units. Score is pro-rated if total projected service units are not met. Possible score of 0 to 20: - Contractor will promote Service Partnership on its website, if applicable (5 points for inclusion on website) - Contractor will display Service Partnership materials and/or poster in service lobby. (5 points for inclusion in lobby) - Contractor will adhere to approved commitments in Service Partnership Marketing Plan (up to 10 points pro-rated for participation on commitments) Beach Service :Possible score of 0 to 20: Board and related 10 Points for attendance at Governing Board meetings; 10 points for Committee attendance (In the event that there are no committee meetings scheduled, the value for attendance at the Governing Board meeting will be 20 14 Web Promotion of Miami Beach Service Partnership The Contractor is required to provide a link to the Miami Beach Service Partnership web page on its organization's web site. In turn, the City of Miami Beach will provide a link to the Contractor web page on its web site. Memoranda of Understanding A Memorandum of Understanding (MOU) reflecting the terms of this agreement as well as commitment to the Miami Beach Service Partnership will be provided and updated as necessary. The MOU must be submitted to the City of Miami Beach prior to execution of the service contract. Governing Board Attendance The Contractor is required to have representation at each calendared Governing Board meeting. If the Contractor fails to have representation at two meetings, the City reserves the right to reduce contracted service levels at its sole discretion. Engagement Strategies The Contractor will adhere to the following engagement strategies in the delivery of services: • Advise the client and his/her parents and/or guardians of the scheduled appointment for Family Group Conference. • Provide client and his/her parents and/or guardians information regarding tutoring and other available services. Evaluation In the continuing effort to ensure programming excellence, clients will be provided with evaluation forms at the end of each programming component to gauge their satisfaction with services provided. The evaluation forms will be provided by the City and must be administered at the following time: • Completion of Services Evaluation Form 15 Monitoring & Performance Reviews The City of Miami Beach reserves the right to inspect, monitor and/or audit the Contractor to ensure contractual compliance. This includes, but is not limited to: • Review of on-site service delivery • Inspection and review of client, budgetary and employee files (for those employees providing services under this contract) The monitoring tool provided by The Children's Trust, "Community and Neighborhood Services System of Care Programmatic Site Visit Form", will be used to guide inspections and monitoring visits. (Copy included herein.) Employee File Review The following documentation must be included in the employee file for those employees providing services under this contract. The City of Miami Beach reserves the right to inspect client files with due notice (at least 48 hours in advance of planned site visit) to ensure adherence to contractual expectations as well as to ensure pre- screening prior to a monitoring visit by The Children's Trust. The following must be included in the employee files: • Employment Application • Evidence of degree/credentials • Job Description Signed by Employee • Evidence of Required Experience • Florida Background Criminal Screening • National FBI Background Criminal Screening (Level2) • Affidavit of Good Moral Character • Proof of Knowledge of Policies & Procedures • Confidentiality Agreement Re: Client Information • Documentation of Agency Training/In-Service Training • I-9 Verification on File Master Calendar The Contractor will notify the City of any client appointment or anticipated service delivery at least 72 hours in advance of the appointment or service delivery for inclusion in the Success University Master Calendar that is distributed to all members of the Miami Beach Service Partnership. The Master Calendar will be updated daily and distributed to the Partnership as needed. 16 Training Requirements Frontline personnel (those conducting trainings) will be required to complete the following trainings prior to service provision: Intake & Assessment Services ^ Program Overview Training ^ Intake & Assessment Training ^ Community OS Software Training ^ Client Evaluation Surve Trainin While initial training expenses are covered by the City, the Contractor agrees to reimburse the City for the early departure (termination) of any trained staff member prior to this contract's termination on a pro-rated basis as follows: Switchboard of Miami Registration Contractor agency will register with Switchboard of Miami to ensure that agency information is accurate and updated. This contractual obligation is directed by The Children's Trust. Agency registration can be done at the following website: www.switchboardmiami.ora Additional Documentation The following documentation must be submitted with this executed agreement: • All required insurance certificates • Copy of current audit • Copy of required business licenses and permits • Copy of notice as recipient of funding from The Children's Trust • Updated Memorandum Of Understanding (MOU) reflecting scope of services and leverage associated with Success University 17 EXHIBIT "B" INVOICING The Contractor agrees to provide the invoicing and services documentation as indicated in the Monthly Progress Report, Monthly Invoice Report, and Status Report Form, as attached to this Exhibit, by the third (3~d) of the subsequent month. 18 b ~ EXHIBIT "C" ATTACHMENTS The following documents are attached: • Intake & Assessment Form (10 pages) • Referral Form (2 pages) • Monthly Progress Report (1 page) • Monthly Invoice Form (1 page) • Status Report Form (1 page) • Services Evaluation Form (1 page) • Programmatic Site Visit Form (9 pages) 19 SiJCC[SS u~w~FS~r~ Date of Assessment: Data Tracker Dater Success University Cltent Intake Data Tracker Client Number:... Client Profile Client Name First Middle Last Client Address Apartment # Zip Code Home Telephone Client Cellular Telephone E-Mail Address Date of Birth City/State/Country of Birth Social Security Number M-DCPS Student ID Number Client Legal Status ^ t!S Citizen ^ US Resident ^ Other ^ Visitor's Visa # ^ Student Visa Sex ^ Male ^ Female ^ Trans ender Race ^ I~rner. Indian Alaska Native ^ BlacklAfrican American ^ Pacific Islander ^ 1/t/hite ^ Uther Ethnicit ^ His anic ^ Haitian ^ Other Preferred Language (Primary Lan ua e S oken in Home ^English ^ S anish ^ Haitian Creole ^ C3ther S ecif School Attended ^ Nautilus Middle ^ Miami Beach Senior Hi h School Current Grade Level ^ 7 'grade ^ 9 Grade ^ 11 Grade ^ 8~n Grade ^ 10~" Grade ^ 12~`' Grade Community Service Hours Submitted to School as of Intake Graduation Re wired - 10 School Attendance (M-ocPS provided> Pxio€~ ~ ,~i ~~, a,. C~r~re~t 5~~hool Year GPA (M-DCPS provided) ~l~r ~;~~~~~~ ';'~~;~ Culrror~t ~ci~iaol Y~~~ ESE Status (M-DCPS verified) ^ Spci~~ i..ear~ing Disab{ed ^ Trainable [Mentally Handicapped ^ Speech Impaired ^ Autistic ^ Emotionally Handicapped ^ HospitallHomebound ^ Educalale Mentally Handicapped ^ DeaflHard of Hearing ^ Language Impaired ^ Clrthopedic-Impaired ^ Gifted ^ Developmentally Delayed ^ Other Health Impaired ^ Visually Impaired ^ Several Mentall Handica ed ^ Profound Mental Handica Is Child Disabled? ^ Yes ^ No Disability Type ^ Autism ^ Hearing Impairment ^ Physical Disability ^ Ciaronic Medical Condition ^ Learning Disability ^ Visual Impairment ^ Emotional Disorder ^ Mental Retardation ^ Other {Specify} ^ Behavioral Disorder Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 Time Start f 1 Parental/Guardian Profile Mother's Name F=irst Middle t,~ast Mother's Address If Different from Client Apartment ~ Zip Cade Home Telephone Mother's Cellular Telephone Mother's E-Mail Address Date of Birth City/State/Country of Birth Social Security Number Driver's License/State ID # Issuing State Client Legal Status ^ US Citizen ^ Visitor`s Visa ^ US Resident /# # ^ Student Visa ^ {.?tiler ~ Preferred Language ^ English ^ Haitian Creole Prima Lan ua e S oken in Home ^ S araist~ ^ Other {S eci Preferred Daysfrime for Contact ^ Sunday ^ htianday ^ Mornings Data Tracker # ^ Tuesday ^ Wednesday ^ Evenings ^ Thursday ^ Friday ^ Afternaans ^ Saturda Father's Name First Middle Last Father's Address If Different from Client Apartment Zip Cade Home Telephone Father's Cellular Telephone Father's E-Mail Address Date of Birth City/State/Country of Birth Social Security Number Driver's License/State ID # Issuing State Client Legal Status ^ US Citizen ^ Visitor`s Visa ^ US resident # # ^ Student Visa ^ Qther # Preferred Language (Primary Language ^ English ^ Haitiar7 Create Spoken in Home) ^ S apish ^ C3ther S eci Preferred Days/Time for Contact ^ Sunday ^ Monday ^ Mornings Data Tracker # ^ Tuesday ^ Wednesday ^ Evenings ^ Thursday ^ Friday ^ Afternoons ^ Saturda Guardian's Name First Middle t.ast ^ Step Parent ^ Foster Parent ^ Grand arent ^ Domestic Partner Guardian's Address If Different from Client Apartment # Zip Cade Home Telephone Guardian's Cellular Telephone Guardian's E-Mail Address Date of Birth City/State/Country of Birth Social Security Number Driver's License/State ID # Issuing State Client Legal Status ^ US Citizen ^ Visitor`s Visa ^ US Resident ## ^ Student visa ^ C)ther # Preferred Language (Primary Language ^ English ^ Haitian Create S oken in Home ^ Spanish ^ Other {S eci } Preferred Days/Time for Contact ^ Sunday ^ Monday ^ Mornings Data Tracker # ^ Tuesday ^ Wednesday ^ Evenings ^ Thursday ^ Friday ^ Afternoons ^ Saturda Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 Time Start f 1 Household Members' Profile Additional Household Members Date of Birth Relation to Client Data Tracker # ^ ~;F.~Ein~ ^ Adulf ^ Other Relative ^ S:bfing ^ AdutS ^ Other RelatEVEi ^ 5:blin3 ^ t\duH ^ O#her R~kative ^ Sblir==~ ^ l~ult ^ Other tZ~lative ^ Shting ^ AdE.elt ^ Other #tc~;l:~tive~~ ^ Sibling ^ AdE.rlt ^ Other Rel~ti~e ^ Sibling ^ Ault ^ €:3thet Rei~;tlyP., ^ Sibling ^ Ariult ^ r3thc~;r t2e;ltative ^ 8bii:?g ^ Adult ^ Other Etclatere ^ Sthiing ^ Adak ^ Okiier Relc+trvm Total # in Household ^ 1 ^ 2 ^ 3 ^ 4 ^ 5 ^ 6 ^ 7 ^ 8 ^ Housing Profile Housin Unit ^ A artment ^ Sin le Hame ^ Mobile Home ^ ®ther Housing Type ^ R~:nt ^ Uwn ^ fJ#her: ^ Lives wtother family ^ Lives w/friends ^ Other # of Bedrooms ^ 1 ^ 2 ^ 3 ^ d ^ 5 ^ 6fmore Housing Adequacy Rre there mare than ~ people per bedroom? ^ Yes ^ No Does housing meet safety requirements? ^ Yes ^ No Has client waved mute than Mice in past 12 menthe? ^ Yes ^ No l~c3es client spend mare than 5C°lo of income on housing? ^ Yes ^ NO Is client at-risk of losing housing? (i.e. late in rent) ^ Yes ^ No Household/Housing Narrative - Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 Time Start L 1 Household Financial Profile Income Profile Parent/Guardian Em to ment .- E to er: $ Parent/Guardian Emplo ment Emplo r: $ S ouse/Si nificant Other Earnin s Empia er: $ Parent SSA Benefits ^ S xl ^ sSDi ^ SS (rezSrement) $ S ouse/Si nificant SSA Benefits ^ sl ^ SSDI ^ SS {retirorrtent) $ S ouse/Si nificant Other Pension souroe: $ Client SSA Benefits ^SSI ^ Survivor's Benefits $ De endent SSI Benefits Cie ancient: $ Dependent SSI Benefits Dependent: $ De endent SSI Benefits Cle endent; $ De endent SSI Benefits C)e endent: $ Household Food Stam Benefits of Persons Covered; $ Tem orar Aid for Need Families Date of Expiration: $ General Public Assistance Source: Expiration: $ Child Su ort Dependent: $ Child Support Dependent: $ Child Su ort De endent; $ Alimon Source: $ Alimon Source: $ Alimon Source; $ Investment Income Source: $ Investment Income Source: $ Other: source: $ Other: Source: $ Other: Monthl Household Income Total Source: $ $ Monthly Household Expenses .- .- .- Housing Utilities ^ Elctricit ^ Natural Gas $ Utilities ^ Telephone ^ Cellular $ Utilities ^ Cable ^ Satellite Service $ Utilities ^ Internet Provider $ Household Insurance ^ Renters ^ Pro art insurance $ Medical Insurance ^ MedicaidlMedicare ^ Private $ Medical Ex ense ^ Co-pa ^ Prescription ^ Medical Care $ Food Ex ense $ Water/Sanitation $ Vehicle Loan/Lease Ex ense ^ Own ^ Lease $ Vehicle Insurance $ Vehicle O eratin Cost ^ Gascaiine ^ Re airs $ Trans ortation Ex ense ^ Putslic Transportation ^ school Trans ort $ Child Support/Alimon ^ Child Support ^Alimon $ Other: Source: $ Other: Source: $ Other: Monthl Household Expenses Source: $ $ ** PLEASE NOTE: If household expenses exceed income, please review referral possibilities to address need. Miami Beach Service PartnershiplUniversal Intake Form -Revised August 2009 Time Start I 1 Household Members Profile Current Services Matrix Indicate all services received/obtained by any members of the client's household. -. Day Care/ Childcare! Adult Da Care .. .- Counseling Services Disability Benefits Educational Services Elder Services Employment Services Food Stamps Food Subsidy Home Care Assistance Housing Assistance Legal Assistance Medicaid Medicare Rehabilitation Services Survivors Benefits SSA TANF Transportation Services Unemployment Compensation Utility Assistance Tutoring Vocational Training Other: Specify Other: Specify Other: Specify Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 Time Start f 1 Household Health Profile Adult Health Profile Service Inquiry Mother/Female Guardian Father/Male Guardian Significant Other: (Name) Other: (Name) When was your last Medics#; Medical: Medical: Med#cal: visit with a doctor? Dental: Dental: Dents#: Dents#: E e: e: E e: E e: ®ther: C)ther: C}ther: ©ther: Have you been ^ Yes ^ Yes ^ Yes ^ Yes hospitalized in the past ^ No ^ No ^ Na ^ No 12 months? ^ Don't Know ^ Dan't naw ^ Don't Knaw ^ Don't Knaw Do you currently have ^ Yes ^ Yes ^ Yes ^ Yes any medical ^ Nca ^ No ^ No ^ Na roblems? ^ Don't Know ^ Dan't Know ^ Dan't Knaw ^ Don't Know DO you have any ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare medical insurance? ^ Private ^ Private ^ Private ^ Private ^ Other ^ Other ^ £}ther ^ C}ther Have you been ^ Yes ^ Yes ^ Yes ^ Yes diagnosed with a ^ No ^ Na ^ Na ^ No mental illness? ^ Dan't Know ^ Dan't Know ^ Don't Knaw ^ Dan't Knaw Do you have a history ^ Yes ^ Yes ^ Yes ^ Yes of alcohol or drug ^ Na ^ Na ^ No ^ Na abuse? ^ Dan't Knaw ^ Don't Knaw ^ Don't Knaw ^ Don't Know Adult Health Profile Narrative - Youth Health Profile Service Inquiry Client: Child # 1: (Name) Child # 2: (Name) Child # 3: (Name) Last visit with a doctor Medics#: Medical: Medics#: Medical: Dents#. Dental: Dents#: Dents#: E e: lW e: E e: E e: Uther: ®ther: C?ther: Other: Has child been ^ Yes ^ Yes ^ Yes ^ Yes hospitalized in the past ^ Na ^ Na ^ Na ^ Na 12 months? ^ Don't l{now ^ Don't Know ^ Dan't Know ^ Don't Know Does child currently ^ Yes ^ Yes ^ Yes ^ Yes have any medical ^ Na ^ Na ^ Na ^ No roblems? ^ Don't Know ^ Don't Know ^ Don't Know ^ Don't Know Does child have any ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare medical insurance? ^ t'rivate ^ Private ^ Private ^ Private ^ tither ^ C7ther ^ Other ^ Qther Has child been ^ Yes ^ Yes ^ Yes ^ Yes diagnosed with a ^ Na ^ Na ^ Na ^ Na mental illness? ^ Don't Kraow ^ Don't Know ^ Don't Know ' ^ Don t Know Youth Health Profile Narrative - Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 Time Start f 1 Youth Risk Factor Profile Factor Client: Child # 1: (Name) Child #2: (Name) Child # 3: (Name) Child is performing ^ ~~~ ^ ~/A ^ ~'~ti ^ ~'~i~ ~f~ ^ t~tA ^ Yes ^ CIA below school level ^ ~ ^u~€~s»~~.r, ^~ ^ ~~ ~~,~~,~~, ^ i~e~ ^ tJnk„~~,~,~ ^ No ^uni:nokda Child has been diagnosed ^ Y€~s~ ^ hJfA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA with a learning disability ^ Na ^unknovrn ^iVp ^ unknown, ^ No ^ unknown ^ NO ^unkr,owrr Child is having behavior ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA problems in school ^ Nf] ^Unknown ^NC? ^ Unktsown ^ No ^unknown ^ Na ^Unknovan Child has a poor ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA attitude towards school ^ Na ^unknown ^No ^unknown ^ No ^ Unknown ^ Na ^Unknown Child has been a ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA victim/witness of domestic ^ No ^unknown ^Na ^unknown ^ Nq ^unknown ^ Na ^unknown violence Child has experienced ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA economic deprivation in ^ Np ^unknown ^Nca ^ ur,knowr, ^ No ^ unknown, ^ No ^ur,k„own the ast 12 months Child lives in a single- ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA Arent home ^ NO ^Urrknown ^NO ^ Unk€,awn ^ N ^ Unknown ^ No ^Unkrtown Child has sibling who ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA dr0 ed out of school ^ Np ^unknown ^Na ^ Unknown ^ Na ^ Unknown ^ No ^Unknowrt Child or sibling is ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA involved in a an ^ No ^unknown ^Nra ^unknown ^ No ^unknown ^ Na ^unknown Client is exposed to ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA drug use in home or ^ Np ^unknown ^Na ^unknown ^ Na ^unknown ^ No ^unknown nei hborhood Child has a parent or ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA caregiver who has ^ Np ^unknown ^Nca ^ Unknown ^ No ^unknown ^ No ^Unkr,awn been arrested Child has access to ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA after-care services Or ^ NtF ^Urrkrrown ^Na ^unknown ^ No ^ Ua,known ^ NO ^Unkr,own adult su envision Child is experiencing ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ne lect ^ No ^unknown ^NCi ^unknown ^ No ^unknown ^ No ^unknown Child has been ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA ^ Yes ^ NIA involved in the juvenile ^ No ^unknown ^Nv ^unknown ^ Ncs ^ Unknown ^ No ^Unkr,own 'ustice s stem Child has missed 10 or ^ `~"r=°~. ^ ~lf~ ^ `i e~ ^ ~;1`~ ^Y es ^ h1IA ^ Yes ^ N16~ more scihoo~ da .5 ^ ~* ^~~23 y~r}(j S:3"t ^i'tl {~ ^ le'1 K77GO4Ct ,~} ^ 7~~ ^ (177{U"t6sNt; ^ Nc~ ^t: (;Hfif'-wn Identified Risk Factors Narrative - (If "Yes" to any above, you must provide detail here) If answer is "Yes" to shaded areas, a strategy must be identified in Care Coordination Plan. Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 Time Start f 1 Natural Support Map and Identified Participants for the FGC •~ ~- Friends ~` ~ Youth i Social Services Community FGC Apuointment Day of the Week: Date• Time• Location• Transportation• Number of Invitees: i Mother: t f Father: ~ E Guardian: Extended Family Member(s): ~ _ i Neighbor(s): ; Friend/Classmate(s): Teacher/Counselor(s): _..._.,..,.._,_.._ ..............____....,_........_....._.._._._.~.____....__._._...____._____.___._.._~4 Other(s) ~coaeh, Godparent, Religious 9 L d _.__._._.._...,.._...,._.~ -___ __._ _ _______._. _....__.._..__.____._ ea er, etc.): i ivnami rseacn aernce rartnersmpiuniversai intake corm - Revisetl August 2009 Time Start f 1 Referral Needs Profile Housing Services Client household in need of affordable housin (housing cost exceeds 50% of income) ^ Yes ^ No Client household in need of rent assistance 3-da notice, eviction notice received) Yes ^ No Client household in need of other housin (inadequate, unsafe, etc.) ^ Yes ^ No Financial Services Client household in need of food assistance (inadequate food for Tamil) ^ Yes ^ No Client household in need of clothin assistance (includin school uniforms) ^ Yes ^ No Client household in need of utilit assistance (late notice, final notice) Yes ^ No Client household in need of trans ortation assistance (bus tokens for school, work, etc.) ^ Yes ^ No Client household in need of em to ment referral (emplo ment for adults, outh) ^ Yes ^ No Client household in need of and eli ible for entitlements (food stamps, TANF, etc.) ^ Yes ^ No If es to an above, lease indicate re ferral rovided: Medical/Counseling Services Client household in need of medical assistance (evaluation, intervention, etc.) ^ Yes ^ No Client household in need of mental health assistance (evaluation, intervention, etc,) ^ Yes ^ No Client household in need of counselin services (individual, famil , marria e, etc. ^ Yes No Client household in need of 7 Habits Famil trainin (family cohesiveness) Yes No Legal Services Client household in need of immi ration services (residenc , as lum, etc.) ^ Yes ^ No Client household in need child su ort enforcement services ^ Yes ^ No Client household in need of landlord/tenant le al services (eviction) Yes ^ No Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 9 Time Start [ 1 Miami Beach Service Partnership Authorization for Release and Exchange of Information The purpose of this Authorization Form is to enable Miami Beach Service Partnership agencies to better serve you and/or your children through coordinated service planning and delivery. Representatives of these agencies may share information in order to arrange for the appropriate and prompt delivery of services as planned. The following Partner agencies may provide you or your family services: ^ Aspira of Florida ^ Ayuda, Inc. ^ Choices et al, Inc. ^ Jewish Community Services ^ Miami Beach Community Health Center ^ Miami-Dade County Public Schools ^ Junior Achievement of Greater Miami ^ The Children's Trust ^ Teen Job Corps ^ Unidad/ Hispanic Community Center ^ South Florida Center for Family Counseling ^ City of Miami Beach Please indicate which information, if any, you do not want to be shared. Note that some agency referrals require the prior release of information to determine eligibility. Please mark all appropriate. ^ Client Demographic Information ^ Education/Training/Skills Background ^ Employment Background & Information ^ Support Service Information c~c~~d~n~e~t~namBn~Sa~,Ren~~rv~~s~ ^ Financial Eligibility Information ^ Housing Information ^ Medical Eligibility Information ^ Legal Background Screening Information ^ Services History Information ^ Other Is there any agency that you do not want us to share your information with? ^ Yes ^ No If yes, please list the agency/agencies below: I understand that this release authorizes an exchange of information between Service Partnership agencies in order to provide me and/or my child(ren) with the most complete and thorough services available. It does not authorize release to any other person or agency except those agencies which are Partnership members or to those agencies to which I am being referred for services. Unless revoked in writing, this release shall remain in force for a period of 24 months from the date of authorization. My signature below indicates that I have been informed of and understand the eligibility information provided within this form and certify that it is true and correct and subject to verification. Any false or misleading responses or submissions on my part may lead to the refusal of services. Parent Signature Date Parent Name -Printed Client Name Intake Worker Signature Date Intake Worker Name -Printed Agency Name Miami Beach Service Partnership/Universal Intake Form -Revised August 2009 Time Start f 1 1~ Data Tracker # Miami Beach Service Partnership Client Information Referral Form Name (Check here if client is a minor ) Place of Birth/ Date of Birth Social Security Legal Status ^ US Citizen ^ US Resident ^ Status Pendin Primary Language Race/Ethnicity ^ English ^ Spanish ^ Creole ^ Other ^ White, Non-Hispanic ^ Hispanic ^ Black, Non-His anic ^ Other Address/Zip Code Home Telephone/ Work Te lephone Marital Status Housing Status ^ Single ^ Divorced ^ DomesticPartnership ^ Own ^ Rent ^ Live w/others ^ Married ^ Se a rated ^ Other ^ Homeless ^ Other Others in Household Household Income ^ Child ^ Adult ^ Employment - $ ^ Child ^ Adult ^ SSA ^ SSI ^ SSDI $ ^ Child ^ Adult ^ Child Support $ ^ Child ^ Adult ^ Pension $ ^ Child ^ Adult ^ Other $ ^ Child ^ Adult ^ Other $ For youth only - For youth only - Current Grade Level Current School ^K ^1^2 ^3 ^4 ^5 ^6 ^7 ^8 ^ 9 ^ 10 ^ 11 ^ 12 ^ Biscayne Elementary ^ North Beach Elementary ^ Fienberg Fisher K-8 Center ^ Nautilus Middle M-DCPS ID # ^ North Beach Elementary ^ Miami Beach Senior Hi h Services History Food Stamp Reci lent ^ Yes ^ No ^ Pending Section 8 Reci lent ^ Yes ^ No Pending SSA Benefits Medicaid/Medicare ^ Yes Pending ^ Yes -Amount $ ^Pendin Reci lent ^ No Current Service Current Service Needs Providers ^ Child Care After Care ^ Disability Benefits ^ ASPIRA ^ Lutheran Services ^ Disability Services ^ AYUDA ^ Miami Beach CHC ^ Educational Services ^ Boys & Girls Club ^ M-Dade Housing Authority ^ Employment Assistance ^ Catholic Charities ^ SSA ^ Food ^ CAA ^ So. FI. Ctr. Family Counseling ^ Housing Services ^ City of Miami Beach ^ Teen Job Corps ^ Legal Services ^ DCF ^ Veteran's Affairs ^ Medical Services ^ Douglas Gardens ^ Volunteers of America ^ Substance Abuse Services ^ HACOMB ^ UNIDAD ^ Youth Intervention Services ^ JCS ^ Other ^ Youth Prevention Services ^ Le al Services of Miami ^ Other ^ Other I understand and have authorized this release and exchange of information between Service Partnership agencies in order to provide me and/or my child(ren) with the most complete and thorough services available. The information I have provided is true and accurate to the best of my knowledge. Client Authorization Staff Signature Date Miami Beach Service Partnership Universal Referral Form -Revised August 2008 • ^ Child Care ^Ayuda, Inc. ^ Aftercare ^Ayuda, Inc. ^ Boys/Girls Club ^ MB PAL ^ MB Recreation • • ^ Clothing ^ Neat Stuff ^ Suited 4 Success ^ Youth ^Ayuda, Inc. ^ JCS #1 ^ MBCHC ^ GLBTOYouth ^ Alliance for GLBTQ Youth ^ Adult ^ Douglas Gardens ^ JCS #1 ^ Family ^Ayuda, Inc. ^ JCS #1 ^ Referral ^Ayuda, Inc. ^ JCS #3 ^ DHS Day Care ^ LHANC - MB ^ LHANC - RT ^ MB - OCS ^ UNIDAD ^ Home Care ^ MD -Human Services ^ Child Care ^Ayuda, Inc. ^ Aftercare ^Ayuda, Inc. ^ Boys/Girls Club ^ MB PAL ^ MB Recreation ^ Employment ^ CAA #2 ^ JCS #1 ^ Unidad ^ Cash . .^ Culmer Center Assistance ^ Edison/Little River .. ~ ~ ~~ ^ Emergency ^ JCS #2 Food ^ St. Joseph's Church ^ St. Patrick's Church ^ Food Stamps ^ DCF ^ Discount Food ^ OCS ^ Emergency I ^ MB - OCS Shelter ^ Affordable ^ MBCDC Housing ^ Transitional ~ ^ Douglas Gardens ^ Disability I ^ Legal Services Benefits ^ Immigration ^ FIAC Services ^UNIDAD ^ LandlordlTenant ^ Medical (u MBCHC Services ^ Dental ^MBCHC Services ^UNIDAD ^ Mental ^ Douglas Gardens Health I-I .ICS #~ ^ Rent ^ CAA #1 Assistance ^ MB - OCS ^ Edison/Little River Center . ., ^ Detox ^JMH Crisis ^ Addiction ^ Central Services Intake •• • ^ Disabled ^ Transit ^ Veterans Agency ^ Elder ^ STS ^ Elder Program ^ EHEAEP ^ Emergency ^Culmer Ctr. Help ^ Edison/Little River Center ^ LHEAP • ~- .• ^ Academic ^Aspira Tutoring ^Ayuda, Inc. ^ Boys/Girls Club ^ MB - OCS ^ Youth ^Aspira Development ^Ayuda, Inc. ^ JCS #3 ^ Employment ^ CAA #2 ^ JCS #1 ^ Teen Job Corps ^ Unidad ^ American Veterans' Food 6632 Collins Avenue/305.867.6060 ^ Alliance for GLBTQ Youth 1175 NE 125th St/1-866-634-8087 ^ Aspira 4100 NE 2nd Avenue/305.576.8494 ^ Ayuda, Inc. 13899 Biscayne Blvd Suite 123 North Miami Beach/ 305.864.6885 ^ Boys & Girls Club 1245 Michigan Avenue/305.673.7760 ^ Central Intake 2500 NW 22nd Avenue/305.638.6540 ^ Community Action Agency #1 6100 NW 7'" Avenue/305.756.2830 ^ Community Action Agency #2 810 NW 28'" Street/305.638.4672 ^ Culmer Service Center 1600 NW 3'd Avenue/305.579.2820 ^ Dept. of Children & Families 945 Pennsylvania Avenue/305.535.5401 ^ DHS/Adult Day Care 150 - 79'" Street/305.571.4342 ^ Douglas Gardens CMHC 701 Lincoln Road/305.531.5341 ^ Douglas Gardens/Mayfair 1960 Park Avenue/305.531.5341 ^ EHEAEP 395 NW 15` Street/305.347.4685 ^ EdisoNLittle River Service Center 150 NW 79'" Street/305.758.9662 ^ Fla. Immigrant Advocacy Center 3000 Biscayne Blvd.l305.573.1106 ^ JMH Crisis Center 1611 NW 12"' Avenue/305.355.7377 ^ Jewish Community Services #1 300 41 Street #216/305.576.6550 ^ Jewish Community Services #2 2056 NE 155`" Streetl305.947.8093 ^ Jewish Community Services #3 Access/ Referral Services/305.576.6550 ^ LHEAP 2902 NW 2"d Avenue/305.438.8614 ^ Legal Services of Greater Miami 3000 Biscayne Blvd./305.576.0080 ^ Little Havana/Miami Beach 533 Collins Avenue/305.532.8576 ^ Little Havana/Rebecca Towers 150 Alton Road/305.572.3736 ^ Miami Beach CDC 945 Pennsylvania Avenuel305.538.0090 ^ Miami Beach CHC #1 710 Alton Road/305.538.8835 ^ Miami Beach -Community Services 555 - 17'" Street/305/6737491 ^ MiamiBeach Police Athletic League 999 -11d' Street/305.531.5636 ^ Miami Beach -Recreation 2100 Washington Avenue/305.673.7730 ^ Miami-Dade Human Services 4500 Biscayne Blvd./305.576.2511 ^ Miami-Dade Transit 111 NW 1 ~` Street/305.770.3131 ^ St. Joseph's Church 8670 Byron Avenue/305.866.6567 ^ St. Patrick's Church 3716 Garden Avenue/305.531.1124 ^ So. FI. Ctr. for Family Counseling 1031 Ives Dairy Rd., # 228/305.914.3789 ^ Teen Job Corps 305.868.0635 ^ Temple Beth Sholom 4144 Chase Avenue/305.538.7231 ^ Unidad/Miami Beach HCC 833 6"' Street/305.532.5350 ^ Other Miami Beach Service Partnership -Universal Referral Form Back -Revised August 2008 Attachment Checklist Invoice ^ Referral Status Report ^ Primary Business Address: Phone: Fax: N A R R A T I V E Contract #: Invoice Date: Reporting Month E-mail: City, ST Zip Code: Web site: N V 0 Contract #; Invoice Date; Bill To: Office of Community Services City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 C E ~ ~ - ~- Subtotal Please make sure to submit all contractually required documentation with invoice. (Performance Balance Due REMITTANCE Date of Receipt; Date ofApprova/; Amount Due; Amount Paid.• Primary Business Address Address 2 City, Sf ZIP Code Country Phone: (340) 555-0167 Fax: (340) 555-0168 E-mail: someone@example.com Web site: www.teenjobcorps.com N 3 U C N Of ~ ~. ~ O L ~ ~ d _ •Q' N • ~ U w ~ H. L »+ R L W d N li ~• , O d a`N 0 aN a ~ d ... ~ 3 0 v c~ ~a 0 w c a .~ ~ i a ~ ~ v c ,~ m~ aw ° o m ~o 0 m o ~ t c N m m H L _ r {Q J d R Z C _~ U a °~ 0 z d R U ~ ~ y 3~ O ~ . ~ O 3 LL _ R ~ L N d ~ W ~ d •L.+ W N O ; ~ + + ~ to C ~~ O y O d d ~ r+ Service Evaluation Form Intake Worker: Training: Intake & Assessment Date: Location: Please take a moment to evaluate today's service. Rate each item from poor to excellent. Your information is used to better improve services. Thanks in advance for your feedback. Content Objective and scope of service Organization of event and agency staff Understandability of communications with staff Relevance of event/service to your objectives Intake Worker Presentation of information Participation by attendees encouraged Discussions managed well Questions responded to satisfactorily Overall Experience Overall experience N/A Poor Fair Good Excellent ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ N/A Poor Fair Good Excellent ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ N/A Poor Fair Good Excellent ^ ^ ^ ^ ^ Please list any further questions you may have about Success University. What was best about the service? What as ect of the service did not meet our ex ectations? ~f l.i va O W L. U }.. ~ ~ W ~r ~ W ~ ("' O V O4 mg _~ C7 Q w d W ZO ~ ~ Q'<! ~ W ~a ZV !~ LL cG !O! G 4 0'W U a a .~ c ~o a L ~ ~ ~ C a. + O a..~ O V ~ ' O Q ';'~ L L L O a~ o> ~ ~ ~+ p1 (0 ~ ~ ~ ~ v ~ ~ U U L O + .+ ~ C C ~ `~ c ~ ~ c a as ~ ~ ^ ' 0 v ~ a +~ ~ L f0 c a v o O 'i O U ;.+ ~ ~ _Q O V U C O O O L O f0 U ~ 'L° U ~ L a~ ^ ""a N w'O C C 0~ ~ o~ 0 U 0 U *k U O *k U a~ 0 a-+ ca 0 c L +~ L LL U C w O cn " a v . ~ 'L U) ~ N ^ a~ ~, u `~ .a ~ (n 0 ~ . . L .O +r ~ ~ ~ ~ O L o ~ ~ Q ~ a i ~ ° ~ v f0 U ~ ~ y O H ~ o ~ ~ > ~ ~ ~p ~ O ~ U ~ •• ~ U ~ ~ ~ a~ i ~ ~ v ~ ~ ~ aci 4 O ~ L O _ O1 ~ L ~i Q a (n a m ~° O U L V L ~o L y.. c o?f C_ ~C C fp a a d C L a N C O U a~ o v z 'Q a Q 0 z ~ o ~ to E `c N °~' ~ ~ C c ~ C ~ N N ~ O ~ p i to V) '~ 'O C 1 i N ~ i' ~ O N O L c O . .. L ~ v o~ u u, ~ ._ c o ~ a o. o ~ w cn L U ~ ~ ~, _ ' 0 0 ~ U 0 ~ ~ U ~ O N O S u 'C aW 4± ~ ~ ~ - 4= N U O i~ C~ N L p ~ ~ ' ~~ ~ . 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