South Florida Center for Family Counseling, Inc. c20 10 — . 2 7 6 -r
PROFESSIONAL SERVICES AGREEMENT
BETWEEN THE CITY OF MIAMI BEACH, FLORIDA
AND SOUTH FLORIDA CENTER FOR FAMILY COUNSELING, INC.
FOR YOUTH SERVICES
RELATED TO THE CITY'S SERVICE PARTNERSHIP INITIATIVE
THIS AGREEMENT made and entered into this 1st day of November, 2010, 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 South Florida Center for Family Counseling, Inc., a Florida Corporation,
(hereinafter referred to as Contractor), whose address is 17801 NW 2nd Ave Suite 207,
Miami, Florida 33169.
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.
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SECTION 2
SCOPE OF WORK (SERVICES)
The Contractor will provide intake and assessment and follow -up contact 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 November 1, 2010.
The scope of work to be performed by Contractor is further detailed in Exhibit "A,"
p Y
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 and 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); (b) Provision of follow -up contact services for up to one hundred and fifty
(150) youth and their families at One Hundred Dollars ($100) per each follow -up
contact for a maximum not to exceed Fifteen Thousand Dollars ($15,000).
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 Thirty Six
Thousand Dollars ($36,000).
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.
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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 October 31, 2011.
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 October 31, 2011.
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
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
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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.
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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.
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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, TRANSFER OR 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
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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:
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TO CONTRACTOR:
South Florida Center for Family Counseling, Inc.
Attn: Mayra Matos, ay a os, xecutive Director Executive
NW 2nd Ave Suite 207,
Miami, Florida 33169
305 - 651 -3534
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.
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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]
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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:
, i 9
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By: i..
City Clerk Mayor
FOR CONTRACTOR: South Florida Center for Family
Counseling, Inc., A Florida
Corporation
ATTEST:
By: By:
A11•
Secrets President
AT G I e kpl2 -jir` /U?- - 1i'!a7'g
Print a Print Name
Corporate Seal
APPROVED AS TO
FORM & LANGUAGE
& FfR EXECUTION
AP .of .441°
gown, • - orne fl late
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EXHIBIT "A"
"SCOPE OF SERVICES"
The Contractor agrees to provide the following services to youth referred to the
Success University program:
Service Documentation of Service
j Intake & Assessment Completed Success University Intake & Assessment
Form including client signature (attached); Copy of
completed Referral Form(s) (attached); Documentation
of service rovided on Community OS Software
Follow -Up Contact ; Completed Client Follow -Up form including client
signature (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.
Follow -Up Contact — A Follow -Up Contact is conducted in person with the client and
the client's primary caregiver. In the event that numerous attempts to make in- person
contact have failed, a phone contact may substitute for a face —to —face meeting only
upon documentation of multiple failed in person attempts. The contact will be no less
than 30 minutes in duration and the document produced must be completed
accurately and in its entirety.
Services will be deemed as provided when the following documentation is provided
within the noted timeframes:
;._.___..___.....__
Documentation __
Submission Deadline
Intake & Assessment Intake & Assessment Form; 72 business hours from
FGC Invited Participants Form provision of service
Referrals Services Referral Form 72 business hours from the
— { identification of client need
Follow - Up Contact Client Follow - Up Form t 72 business hours from
provision of service
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Service Deliverables
Service Unit of Service Service Location Timeframe
intake & Assessment 1 for each of up to Client Home All eligible intakes
150 youth will be completed
within thirty (30)
days of receipt of
i appointment
Follow -Up Contact 1 for each of up to Client Home All follow -ups will be
150 youth completed within
one hundred and
twenty (120) days of
completion of intake
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.
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 (3` 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. Reports are due on the following dates:
•Friday, Dec. 3` 2010 •Friday, June 3` 2011
•Monday, Jan. 3` 2011 •Tuesday, July 5 2011
•Thursday, Feb. 3` 2011 •Wednesday, Aug. 3 2011
•Thursday, March 3` 2011 •Tuesday, Sept. 6 2011
•Monday, April 4 2011 •Monday, Oct. 3 2011
•Tuesday, May 3 2011 •Thursday, Nov. 3` 2011
Monthly reports and reimbursement requests will be submitted via any of the
following methods:
• Electronic mail
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• 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.
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 Rating Rationale & Score
Timely and accurate submission of ➢ "0" for failing to submit on time
monthly progress report ➢ 10 for submitting on time
Timely and accurate submissions of ➢ "0" for failing to submit accurate report
monthly financial reports (reimbursement with back -up material on time
requests) ➢ "10" for submitting accurate report on
time
Delivery of contracted service units Possible score of 0 to 50 based upon
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completion of monthly projected service
units. Score is pro -rated if total projected
service units are not met.
Promotion of the Miami Beach Service 1 Possible score of 0 to 10:
Partnership ➢ Contractor will promote Service
Partnership on its website, if applicable (3
points for inclusion on website)
➢ Contractor will display Service
Partnership materials and /or poster in
service lobby. (2 points for inclusion in
lobby)
➢ Contractor will adhere to approved
commitments in Service Partnership
Marketing Plan ( up to 5 points pro-rated
forjarticipation on commitments)
Attendance at Miami Beach Service7 Possible score of 0 to 20:
! Partnership Governing Board and related 10 Points for attendance at Governing
committee(s) meetings 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 1.
1 meeting will be 20.)
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 but at an
amount no greater than five percent of the contract award.
Engagement Strategies
The Contractor will adhere to the following engagement strategies in the delivery of
services:
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• Advise the client and his /her parents and /or guardians of the scheduled
appointment for Family Group Conference as documented via the appointment
card.
• Provide client and his /her parents and /or guardians information regarding the
importance of adhereing to school attendance policies including receipt of the
state's mandatory school attendance rules.
• Provide client and his /her parents and /or guardians information regarding the
Care Coordination process and other available services including the receipt of
the program services flowchart.
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 Intake and Assessment
• Completion of in person Follow -Up Contact
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:
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• Employment Application
• Evidence of degree /credentials
.• Job Description Signed by Employee
• Evidence of Required Experience
• Florida Background Criminal Screening
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• 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 for Contracted Services
Provided
• 1 -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 via Community OS Software. The Master
Calendar will be updated daily and distributed to the Partnership via Community OS
Software.
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 Survey Training
Follow Up Services El Program Overview Training
❑ Follow Up Services Training
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:
................
Training .................._ ..._.............. Cost
Program Overview Training__ $66.56 µ
Intake & Assessment Training _ $133.12
17
j ..... Community Training Train ...... ...............___..............-----.___.........................._._................ �_._..._...._._..._...._—___---..__._ ._.._......_- �--- __..._-- ___._- _.____..__.......
Community _...... ... __........_ n iin -__–_..._..__._._._. ....._..- .__._.......__........ -- - - - -- _._.^
Client Evaluation Survey Training $16.64
Follow Up Training $66.56
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. orq
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
18
EXHIBIT "B"
INVOICING
The Contractor agrees to provide the invoicing and services documentation as
indicated in the Monthly Progress Report and Monthly Invoice Report, as attached to
this Exhibit, by the third (3 of the subsequent month.
19
EXHIBIT "C"
ATTACHMENTS
The following documents are attached:
• Intake & Assessment Form (10 pages)
• Referral Form (2 pages)
• Follow Up Contact Form (2 pages)
• Monthly Progress Report (1 page)
• Monthly Invoice Form (1 page)
• Services Evaluation Form (1 page)
• Programmatic Site Visit Form (9 pages)
20
ME
ER
Date of Assessment:
,. .Data Tracker Date:
Success University Client Intake Data "Tacker 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 ❑ US Citizen ❑ Visitors Visa
❑ US Resident #
# ❑ Student Visa
❑ Other #
Sex ❑ Male ❑ Female ❑ Transgender
Race ❑ Amer. Indian/ Alaska Native ❑ Pacific islander 0 Other
❑ Black /African American ❑ White
Ethnicity 0 Hispanic ❑ Haitian ❑ Other
Preferred Language (Primary ❑English ❑ Haitian Creole
Language Spoken in Home) ❑ Spanish 0 Other (Specify)
School Attended ❑ Nautilus Middle ❑ Miami Beach Senior High School
Current Grade Level ❑ 7m Grade ❑ 9th Grade ❑ 11th Grade
❑ 8 Grade ❑ 10 Grade 0 12 Grade
Community Service Hours Submitted to School as of Intake
(Graduation Required —10)m r
School a�Attendan"ce..(M n0P$ provided) . ° Prioru ehool r Year � rren g ; Y ear
GPA (M provided} " .: ;Prior School Year. W 3 "C entzSchol "Y
oear
ESE Status (M - DCPS verified) ❑ Specific Learning Disabled ❑ Trainable Mentally Handicapped
0 Speech Impaired ❑ Autistic .
❑ Emotionally Handicapped ❑ Hospital /Homebound
❑ Educable Mentally Handicapped ❑ Deaf /Hard of Hearing
❑ Language impaired ❑ Orthopedic - Impaired
❑ Gifted ❑ Developmentally Delayed
❑ Other Health impaired ❑ Visually impaired
❑ Severely Mentally Handicapped ❑ Profound Mental Handicap
Is Child Disabled? ❑ Yes 1 ❑ No
Disability Type ❑ Autism ❑ Hearing Impairment ❑ Physical Disability
❑ Chronic Medical Condition 0 Learning Disability ❑ Visual Impairment
❑ Emotional Disorder ❑ Mental Retardation ❑ Other (Specify)
❑ Behavioral Disorder
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 1
Time Start f 1
Parental /Guardian Profile
Mother's Name First Middie Last
Mother's Address If Different from Client Apartment # Zip Code
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
❑ Other #
Preferred Language ❑ English ❑ Haitian Creole
(Primary Language Spoken in Home) ❑ Spanish ❑ Other (Specify)
Preferred Days/Time for Contact ❑ Sunday ❑ Monday ❑ Moorings Data Tracker #
❑ Tuesday ❑ Wednesday ❑ Evenings
❑ Thursday ❑ Friday ❑ Afternoons
❑ Saturday
Father's Name First Middle Last
Father's Address If Different from Client Apartment # Zip Code
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
❑ Other #
Preferred Language (Primary Language ❑ English ❑ Haitian Creole
Spoken in Home) ❑ Spanish ❑ Other (Specify)
Preferred Days /Time for Contact ❑ Sunday 0 Monday 0 Mornings Data Tracker #
❑ Tuesday ❑ Wednesday ❑ Evenings
❑ Thursday ❑ Friday ❑ Afternoons
❑ Saturday
Guardian's Name First Middle Last
o Step Parent 0 Foster Parent
0 Grandparent 0 Domestic Partner
Guardian's Address If Different from Client Apartment # Zip Code
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
❑ Other #
Preferred Language (Primary Language ❑ English ❑ Haitian Creole
Spoken in Home) ❑ Spanish 0 Other (Specify)
Preferred Days/Time for Contact ❑ Sunday ❑ Monday ❑ Mornings Data Tracker #
❑ Tuesday ❑ Wednesday ❑ Evenings
❑ Thursday ❑ Friday 0 Afternoons
Saturday
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 2
Time Start 1 1
Household Members' Profile
Additional Household Members Date of Birth Relation to Client Data Tracker #
o Siblin ❑ Adult a Other
Relative
❑ Sibling ❑ Adult 0 Other
Relative,
❑ &blind 0 Adult ❑ Other
Relative
0 S bhnr 0 Adult 0 Other
Relative
Q Sibling 0 Adult 0 Ottte:
Relative
O Siang 0 Adult 0 Met
Relative
o Sibling 0 Adult 0 Ofner
Relative
o Sibling 0 Adult 0 Other
Relative
o Sibling 0 Adult 0 Other
Relative
O Sibling 0 Adult 0 Other
Relative
Total # in Household ❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 0 6 ❑ 7 1 ❑ 8 ❑
Housing Profile
Housing Unit ❑ Apartment ❑ Single Home 1 ❑ Mobile Home ❑ Other
Housing Type ❑ Rent ❑ Own ❑ Other:
❑ Lives w /other family
❑ Lives w /friends
❑ Other
# of Bedrooms ❑ 1 ❑ 2 ❑ 3 1 4 1❑ 5 ❑ 6 /more
Housing Adequacy Are there more than 2 people per bedroom? ❑ Yes ❑ No
Does housing meet safety requirements? ❑ Yes ❑ No
Has client moved more than twice in past 12 months? ❑ Yes ❑ No
Does client spend more than 50% of income on housing? ❑ Yes ❑ No
Is client at -risk of losing housing? (Le. late in rent) ❑ Yes ❑ No
Household /Housing Narrative -
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 3
Time Start i
Household Financial Profile
Income Profile
Income Source Detail Monthly Benefit /Earnings
Parent /Guardian Employment Employer: $
Parent/Guardian Employment Employer: $
Spouse /Significant Other Earnings Employer: $
Parent SSA Benefits 0 SSI ❑ SSDI 0 SS (retirement) $
Spouse /Significant SSA Benefits ❑ SSI ❑ SSDI ❑ SS (retirement) $
Spouse /Significant Other Pension Source: $
Client SSA Benefits 0 SSI 1 ❑ Survivor's Benefits $
Dependent SSI Benefits Dependent: $
Dependent SSI Benefits Dependent: $
Dependent SSI Benefits Dependent: $
_Dependent SSI Benefits Dependent $
Household Food Stamp Benefits # of Persons Covered: $
Temporary Aid for Needy Families Date of Expiration: $
General Public Assistance Source: I Expiration: $
Child Support Dependent: $
Child Support Dependent: $
Child Support Dependent: $
Alimony Source: $
Alimony Source: $
Alimony Source: $
Investment Income Source: $
Investment income Source: $
Other: Source: $
Other: Source: $
Other: Source: $
Monthly Household Income Total $
Monthly Household Expenses
Expense Source Detail Monthly Expense /Cost
Housing
Utilities ❑ Electricity ❑ Natural Gas $
Utilities ❑ Telephone ❑ Cellular $
Utilities 0 Cable 0 Satellite Service $
Utilities , ❑ Internet Provider $
Household Insurance ❑ Renters ❑ Property insurance $
Medical Insurance ❑ Medicaid /Medicare 0 Private $
Medical Expense ❑ Co 1 ❑ Prescription 1 0 Medical Care $
Food Expense $
Water /Sanitation $
Vehicle Loan /Lease Expense 0 Own 0 Lease $
Vehicle Insurance $
Vehicle Operating Cost ❑ Gasoline 0 Repairs $
Transportation Expense 0 Public Transportation 0 School Transport $
Child Support/Alimony ❑ Child Support ❑ Alimony $
Other: Source: $
Other: Source: $
Other: Source: $
Month! Household Ex . enses $
** PLEASE NOTE: If household expenses exceed income, please review referral possibilities to address need.
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 4
Time Start l 1
Household Members Profile
Current Services Matrix
Indicate all services received /obtained by any members of the client's household.
Service Received Name(s) of those household Notes /Comments
members receiving services
Day Care/ Childcare/
Adult Day 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 5
Time Start
Household Health Profile
Adult Health Profile
Mother /Female Guardian F ather /Male Guardian S ignificant Other: (Name) O ther: Name
Service Inquiry (Name)
When was Y our last Medical: Medical: Medical: Medical:
visit with a doctor? Dental: Dental: Dental: Dental:
Eye: Eye: Eye: Eye:
Other: Other: Other: Other:
Have you been ❑ Yes ❑ Yes ❑ Yes ❑ Yes
hospitalized in the past ❑ No ❑ No ❑ No ❑ No
12 months? ❑ Don't Know ❑ Don't Know ❑ Don't Know ❑ Don't Know
Do you currently have ❑ Yes ❑ Yes ❑ Yes 0 Yes
any medical ❑ No ❑ No ❑ No ❑ No
problems? ❑ Don't Know ❑ Don't Know ❑ Don't Know ❑ Don't Know
Do you have any ❑ Medicaid ❑ Medicare ❑ Medicaid ❑ Medicare 0 Medicaid ❑ Medicare ❑ Medicaid O Medicare
medical insurance? ❑ Private ❑ Private ❑ Private ❑ Private
❑ Other ❑ Other ❑ Other ❑ Other
Have you been ❑ Yes ❑ Yes ❑ Yes ❑ Yes
diagnosed with a ❑ No ❑ No ❑ No ❑ No
mental illness? 0 Don't Know ❑ Don't Know ❑ Don't Know ❑ Don't Know
Do you have a history ❑ Yes ❑ Yes 0 Yes ❑ Yes
of alcohol or drug 0 No ❑ No ❑ No ❑ No
abuse? ❑ Don't Know ❑ Don't Know ❑ Don't Know ❑ 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 Medical: Medical: Medical: Medical:
Dental: Dental: Dental: Dental:
Eye: Eye: Eye: Eye:
Other: Other: Other: Other:
Has child been ❑ Yes 0 Yes ❑ Yes ❑ Yes
hospitalized in the past ❑ No ❑ No ❑ No ❑ No
12 months? ❑ Don't Know ❑ Don't Know ❑ Don't Know ❑ Don't Know
Does child currently ❑ Yes ❑ Yes ❑ Yes ❑ Yes
have any medical ❑ No ❑ No ❑ No ❑ No
problems? ❑ Don't Know ❑ Don't Know ❑ Don't Know ❑ Don't Know
Does child have any ❑ Medicaid 0 Medicare ❑ Medicaid ❑ Medicare 0 Medicaid ❑ Medicare ❑ Medicaid ❑ Medicare
medical insurance? ❑ Private ❑ Private 0 Private ❑ Private
❑ Other ❑ Other ❑ Other ❑ Other
Has child been ❑ Yes ❑ Yes ❑ Yes ❑ Yes
diagnosed with a ❑ No ❑ No ❑ No ❑ No
mental illness? ❑ Don't Know ❑ Don't Know ❑ Don't Know ❑ Don't Know
Youth Health Profile Narrative —
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 6
Time Start f 1
Youth Risk Factor Profile
Factor Client: Child # 1: (Name) Child #2: (Name) Child # 3: (Name)
Child is performing :❑ Yes ❑ INCA ❑ Yes ` 13:N/A:' 0 Yes ❑ N A ::0 Wes ❑:`NIA • below school level '` .O'No ; '❑unknown 70No unknown ° .❑4No ❑, Unknown ' ;.❑'No '❑unknown
Child has been diagnosed ❑ 'Yes ❑ N/A ❑ Yes 10 N/A ❑ Yes ❑ NIA ❑ Yes ❑ N/A
with a learning disability ❑ No ❑Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
Child is having behavior ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ NIA
problems in school ❑ No ❑Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ['Unknown
Child has a poor ❑ Yes ❑ N/A ❑ Yes ❑ NIA ❑ Yes ❑ NIA ❑ Yes 0 N/A
attitude towards school ❑ No ['Unknown ❑NO ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
Child has been a ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ NIA ❑ Yes ❑ NIA
victim /witness of domestic ❑ No ❑Unknown ❑NO ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
violence
Child has experienced ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A
economic deprivation in ❑ No ❑Unknown ONO ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
the past 12 months
Child lives in a single- ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A
parent home ❑ No ['Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
Child has sibling who ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A
dropped out of school ❑ No ❑Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
Child or sibling is ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A
involved in a gang ❑ No ❑Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
Client is exposed to ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A
drug use in home or ❑ No ['Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No OUnknown
neighborhood
Child has a parent or 0 Yes ❑ N/A ❑ Yes ❑ NIA ❑ Yes ❑ NIA ❑ Yes 0 N/A
caregiver who has 0 No ❑unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ❑unknown
been arrested
Child has access to ❑ Yes ❑ NIA ❑ Yes ❑ NIA ❑ Yes ❑ N/A ❑ Yes ❑ NIA
after -care services or ❑ No ❑Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
adult supervision
Child is experiencing 0 Yes ❑ NIA ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A
neglect ❑ No ❑Unknown ❑NO ❑ Unknown ❑ NO ❑ Unknown ❑ No ❑Unknown
Child has been ❑ Yes ❑ N/A ❑ Yes ❑ N/A ❑ Yes ❑ N/A 0 Yes ❑ N/A
involved in the juvenile ❑ No ['Unknown DNo ❑ Unknown ❑ No ❑ Unknown ❑ No ❑Unknown
justice system
°Child hasamis sed I, of W, alit t YID ' ��i< .D�s ,.❑� ❑ 0 - .❑1NIA
-"� � �r -mss = � Y �- v �,x A 1 - .�,. ,�k
moretech l vs ;❑� ? t,4ilrowrc. * i tti rrEr , 1. 4 NUiknow4 sax i�►NCt; 51:364 ,
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 7
Time Start ( 1
Natural Support Map and Identified Participants for the FGC
Reli FGC Appointment
Cultural
Q Extended
Family Day of the Week:
Date:
�• School
Friends
Youth
Time:
Location:
Social R ecr e ation
Services
Transportation:
Community 411,
Number of Invitees:
'i ame(s) and Relationship Address, Cite, Zip Code Phone#'s Email Address(es)
Mother:
Father:
Guardian:
Extended Family Member(s): i
Neighbor(s):
Friend /Classmate(s):
Teacher /Counselor(s):
Other(s) (Coach, Godparent, Religious
Leader, etc.):
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 8
Time Start f 1
Referral Needs Profile
Housing Services
Client household in need of affordable housing (housing cost exceeds 50% of income) ❑ Yes ❑ No
Client household in need of rent assistance (3 -day notice, eviction notice received) ❑ Yes ❑ No
Client household in need of other housing (inadequate, unsafe, etc.) ❑ Yes ❑ No
If es to an above, •lease indicate referral .rovided:
Agency Referred To Date of Initial Referral Date of Follow -up
Financial Services
Client household in need of food assistance (inadequate food for family) ❑ Yes ❑ No
Client household in need of clothing assistance (including school uniforms) ❑ Yes ❑ No
Client household in need of utility assistance (late notice, final notice) ❑ Yes ❑ No
Client household in need of transportation assistance (bus tokens for school, work, etc.) ❑ Yes ❑ No
Client household in need of employment referral (employment for adults, youth) ❑ Yes ❑ No
Client household in need of and eligible for entitlements (food stamps, TANF, etc.) ❑ Yes ❑ No
If es to an above, please indicate referral •rovided:
Agency Referred To Date of Initial Referral Date of Follow - up
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 counseling services (individual, family, marriage, etc.) ❑ Yes ❑ No
Client household in need of 7 Habits Family training (family cohesiveness) ❑ Yes ❑ No
If es to an above, please indicate referral provided:
Agency Referred To Date of Initial Referral Date of Follow - up
Legal Services
Client household in need of immigration services (residency, asylum, etc.) ❑ Yes ❑ No
Client household in need child support enforcement services ❑ Yes ❑ No
Client household in need of landlord /tenant legal services (eviction) ❑ Yes ❑ No
If es to an above, •lease indicate referral provided:
Agency Referred To Date of Initial Referral Date of Follow -up
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 9
Time Start l 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 ( induding entitlements a current services)
❑ 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 Intake Worker Signature
Date Date
Parent Name — Printed Intake Worker Name — Printed
Client Name Agency Name
Miami Beach Service Partnership /Universal Intake Form - Revised August 2009 10
Time Start i 1
Data Tracker #
Miami Beach Service Partnership Referral Form
Client Information
Name (Check here if client is a minor 0) Place of Birth/ Date of Birth
Social Security Legal Status
❑ US Citizen ❑ US Resident ❑ Status Pending
Primary Language Race /Ethnicity
❑ English ❑ Spanish ❑ Creole ❑ Other ❑ White, Non - Hispanic ❑ Hispanic
❑ Black, Non - Hispanic ❑ Other
Address /Zip Code Home Telephone/ Work Telephone
Marital Status Housing Status
❑ Single ❑ Divorced ❑ Domestic Partnership ❑ Own ❑ Rent ❑ Live w /others
❑ Married ❑ Separated ❑ 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
0 0 0 0 0 0 0 0 0
❑ 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 High
Services History
Food Stamp ❑ Yes ❑ Pending Section 8 ❑ Yes ❑ Pending
Recipient ❑ No Recipient ❑ No
SSA Benefits Medicaid /Medicare ❑ Yes ❑ Pending
❑ Yes - Amount $ ❑ Pending Recipient ❑ 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
❑ Legal 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 September 2010
Child Care /Aftercare Services Medical Services DAlliance for GLBTQ Youth
❑ Child Care ❑ Ayuda, Inc. ❑ Medical ❑ Miami Beach 1175 NE 125th St/1-866-634-8087
❑ Aftercare ❑ Ayuda, Inc. Services Community Health ❑A ❑Ayududa4100 NE 2ndAve.305.576.8494
a, Inc.
❑ Boys /Girls Club Center 7118 Byron Ave. / 305.864.6885
❑ MB PAL ❑ Dental ❑ MBCHC DBoys & Girls Club
❑ MB Recreation Services ❑ UNIDAD 1245 Michigan Avenue /305.673.7760
Clothing Services ❑Bridge, The 2810 N.W. South River
❑ Mental Do Douglas Gardens Drive / 305 - 635 -8953
Clothing Neat Stuff
❑ 9
❑ g ❑ Health ❑Central Intake
❑ Dress for Success ❑ JC S #1 2500 NW 22 Avenue/305.638.6540
Counseling Services Rent Assistance ❑ CINS /FINS 1825 NW 167 St. Ste.
❑ Youth ❑ Institute CFH ❑ Rent ❑ CAA #1 102 / 305.474.1707/ 305.474.1738
❑ JCS #1 Assistance ❑ MB - OCS ❑ Community Action Agency #1
❑Stand Up ($) ❑ Edison /Little 6100 NW 7 Avenue/305.756.2830
❑ GLBTQ ❑ Alliance for
River Center ❑ Community Action Agency #2
833 6th St 1 FI. 33139 /305- 672 -1705
Youth GLBTQ Youth Substance Abuse Services ❑ Culmer Service Center
❑ Adult ❑ Douglas Gardens ❑ Detox 0 JMH Crisis 1600 NW 3' Avenue/305.579.2820
❑ JCS #1 ❑ Dept. of Children & Families
❑ Stand Up ($) ❑ Addiction ❑ Central Intake 945 Pennsylvania Avenue/305.535.5401
❑ Family ❑ Institute CFH ❑ Human Services / Adult Day Care
❑ Ayuda, Inc. Services 150 — 79 Street/305.571.4342
❑ JCS #1 Transportation Assistance ❑ Douglas Gardens CMHC
❑ Stand U • $ ❑ Disabled ❑ Transit Agency 701 Lincoln Road/305.531.5341
❑ Veterans ❑ Douglas Gardens /Mayfair
Elder Services ❑ Elder 1960 Park Avenue /305.531.5341
CJ Referral ❑ JCS #3 ❑ STS DEHEAEP 395 NW 1 St 305.347.4685
❑ DHS Day Care ❑Edison /Little River Service Center
❑ LHANC — MB Utilities Assistance 150 NW 79 Street/305.758.9662
❑ LHANC — RT ❑ Elder Program ❑ EHEAEP ❑ Fla. Immigrant Advocacy Center
❑ MB - OCS 3000 Biscayne Blvd./305.573.1106
❑ Institute est 66th St. Child & hams 58 Health
❑ UNIDAD ❑ Emergency ❑ Culmer Ctr.
430 West 66th St. Hialeah /305- 558 -2480
❑ Home Care ❑ MD — Human Help ❑ Edison /Little ❑ JMH Crisis Center
Services River Center 1611 NW 12 Avenue/305.355.7377
Employment Assistance ❑ LHEAP ❑JCS #1 300 41 St. #216/305.576.6550
❑ Employment ❑ CM #2 Youth Development ❑JCS #2 2056 NE 155 St.305.947.8093
❑ JCS #1 ❑ Academic ❑JCS #3Access /Referrals305.576.6550
❑ Aspira ❑ LHEAP 2902 NW 2 305.438.8614
❑ Unidad Tutoring ❑ Boys/Girls Club
❑ Youth Co -Op ❑Legal Services of Greater Miami
❑ MDC Libraries 3000 Biscayne Blvd./305.576.0080
Financial Assistance ❑ Little Havana/Miami Beach
❑ Cash ❑ Culmer Center ❑ Youth ❑ Ayuda, Inc. 533 Collins Avenue/305.532.8576
Assistance ❑ Edison /Little River Development ❑ JCS #3 ❑ Little Havana/Rebecca Towers
Food Assistance ❑Talconcy — 150 Alton Road/305.572.3736
❑ Emergency 0 JCS #2 FAST 9 M Pen CDC
nsyyl an a Avenue /305.538.0090
Food ❑St. Joseph's Church ❑MDC - ❑ Miami Beach CHC #1
:1St. Patrick's Church Prevention 710 Alton Road/305.538.8835
❑ Food Stamps ❑ DCF DSwitchboard of ❑ Miami Beach — Community Services
❑ Discount ❑ Miami Beach - Miami - PHASE 555 — 17 Street/305/6737491
Food OCS ❑ CAA #2 0M i mi each/PPolice Athletic League
Housing Assistance
El Emergency ❑ MB —OCS ❑ Employment El Miami Beach — Recreation
g y ❑ JCS #1 2100 Washington Avenue/305.673.7730
Shelter ❑ Teen Job Corps
❑ Unidad ❑ Miami -Dade Human Services
❑ Affordable ❑ MBCDC 4500 Biscayne Blvd./305.576.2511
❑ Miami-Dade Transit
Housing ['Youth ❑The Village 111NW 1 St eet/305.770.3131
Substance Abuse South ❑ St. Joseph's Church
❑ Transitional 0 Douglas Internal Referrals (Success 8670 Byron Avenue/305.866.6567
Housin• Gardens /Ma air University direct services) ❑ St. Patrick's Church
Legal Services 3716 Garden Avenue/305.531.1124
❑ Disability ❑ Legal Services 0 Academic ❑ MBSH Room ❑ So. FI. Ctr. for Family Counseling
Benefits Tutoring 2703 1031 Ives Dairy Rd., # 228/305.914.3789
❑ Immigration ❑ FIAC ❑ Youth ❑ 7 Habits of ❑ Teen Job Corps 305.868.0635
Services Development Highly Effective ❑ Unidad /Miami Beach HCC
El Landlord/Tenant • Le•al Teens 833 6 Street/305.532.5350
Other Services ❑Family 07 Habits ❑Youth Co -Op 7900 NW 27 Ave. 305 -
Communication Families 693-2060 or 305-643-3300
❑ ❑ ❑ Employment ❑ Teen Job Corps ❑ Other
❑ ❑ ❑ Unidad
Miami Beach Service Partnership - Universal Referral Form Back — Revised September 2010 2
Case Worker
Contact Date
AM Data Tracker Date
Client Name First Middle Last
Client Address Apartment # Zip Code
Home Telephone Cellular Telephone E -Mail Address
Contact Date Contact Location
O Home 0 Other 0 Phone Contact
Indicate Persons Present 0 Client 0 Mother/ Step- Mother 0 Father/ Step- Father
0 Other Females # 0 Other Males #
Phone Call Log Date: Date: Date:
Time: Time: Time:
0 Message 0 No Answer 0 Message 0 No Answer 0 Message 0 No Answer
Referral Follow -up
Please indicate the service needs recognized in prior visits and their subsequent follow -up.
Service Need Agency Referred Current Status
Current Home Status
Please provide an update on the client and family's status for each category below.
Housing
(Housing situation
including affordability)
Financial
(Employment, living costs,
etc.)
Familial
(Family dynamics,
relationships, etc.)
Educational
(Academic progress,
school attendance, etc.)
Health
(Physical, mental and
dental)
Success University Audit
Indicate the Success University components /services that have been accessed by client as of this contact.
0 Intake & Assessment 0 Referral Services 0 Family Conferencing 0 Mental Health
0 7 Habits Teens /Families 0 Employment Services 0 MB Helpers Client/ Parent O Discount Food Program
Success University Client Contact Form 1
Revised January 2011
Truancy Reduction Update
Indicate the status of the client's truancy reduction goals. Reference the Care Coordination Plan and /or FGC
Attendance Contract
Additional Narrative /Observations
Indicate any additional comments including observations regarding the client and /or family.
New Needs Identified
Indicate any new needs that require referral services.
Need Identified Referral Provided /Agency
Service Reminders
Please ensure you review all of the items below with client and family.
Service Reminder Yes No
Did you ensure that all contact information is accurate and up -to -date? O O
Did you provide family with this month's Discount Food Program information? O O
Did you remind client and parent of the importance of adhering to the Attendance Contract? O O
Next Scheduled Encounter
Indicate your next scheduled encounter with client and location.
Date Time Location Purpose
O Family Conferencing
O Follow -up Home Visit
O No follow -up expected
Success University Client Contact Form 2
Revised January 2011
1 AM I B C /� '"" H Monthly IMF M (•;,f- ,i�,,,, H Office of Community Services
Project Profile
por=ting/Agency
roject Success University
1Reportirigl!ennd ❑ November /10 ❑ December /10 ❑ January/11 ❑ February /11
❑March /11 ❑ April/1 1 ❑ May/1 1 ❑ June /11
• ❑ July /11 ❑ August/1 1 ❑ September /11 ❑ October /11
Please provide a narrative summary for each section, as applicable.
e vur lfll�[�age Please prauide rracr tip „far i g ie r ini t af�rfl l e f s rvic es inbir� ii
pr�lecris�rnr�tfr. �mte�d�i��icm�lert�er�tati�r�tbispa�t ^�rtk►} ..- �'�� � ' �' x � . ' � � �
Percentage of Funds Expended to Date
llg1K� �1t+ t c <
.e,3. e ly `i p3iv.,�Tt g� �i'' :r , k`, T xi
tom: U if i i i ' P gi rt .,.. it,'Ai $. ' '^j: 5 : ,F4 k'SI E` z Rfi a i ra 5l
3
x. _ . . Y. �4. �..... ".. ` .'...a. '^ . ^ ?. .,.. w . .^ �?: . z' s
Prepared By Signature Date
Office of Community Services /Grant Reimbursement Request
Grant Name Funder
Success University The Children's Trust
Contract Number Awarded Amount
Reporting Period
Initials
Expended Thus Far $ - 1 Available Balance $
This Request $ -
Balance Remaining $ -
Fiscal Summary
Intake & Assessments `$ $ - $ -
Follow -Up Contacts $ $ - $ -
Family Group Conferencing $ - $ - $ -
Employment Services $ - $ - $ -
Mental Health Services $ $ - $ -
$' $ - $
$.: $ - $
;$ $ $ -
TOTALS $ "$ $ - $ -
Uocrrrnent,ation Ctie( laliit
Not
Documentation Submitted Submitted
Service delivery documentation
List of clients served and services provided
- ;:- Leverage /Match
Staff Member -Hourly "Rate ;! 'Hourly : Benefits 4l of. Flours Line — total- j
$ $ $
$ :$ :$
$ $ $
$ $ -
;Space: & > Otherin-Kincl . Value %Unit Cost .Unit :Quantity :UneTotal
-
$ $'
nddl ire -i<r d -
Leverage Iota) $ -
I certify that the information provided above is accurate to the best of my knowledge and that I have included all documentation required to ascertain the
. delivery of services as delineated in our contract with the City of Miami Beach.
Signature of Authorized Agency Representative Date
Date Received by City of Miami Beach
:Amount AuthorizedforReimbursement
Service Evaluation Form
Worker: Training:
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.
I
Content
N/A Poor Fair Good Excellent
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
N/A Poor Fair Good Excellent
Presentation of information ❑ ❑ ❑ ❑ ❑
Participation by attendees encouraged ❑ ❑ ❑ ❑ ❑
Discussions managed well ❑ ❑ ❑ ❑ ❑
Questions responded to satisfactorily ❑ ❑ ❑ ❑ ❑
Overall Experience
N/A Poor Fair Good Excellent
Overall experience ❑ ❑ ❑ ❑ ❑
Please list any further questions you may have about Success University.
What was best about the service?
What aspect of the service did not meet your expectations?
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