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Ayuda, Inc., for Youth Services Agreement PROF~SIONAL SERVICES AGt~EEMENT BETWEEN THE CITY OF MIAMI BEACH, FLORIDA AND AYUDA, INC. FOR YOUTH SERVICES RELATED TO THE CITY'S SERVICE PARTNERSHIP INITIATNE THIS AGREEMENT made and entered into this 1st day of December, 2007, 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 1106 Normandy Drive, Miami Beach, Florida, 33141. 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 °An 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. ~~~~~~ x'~ ~~ 8~ i ~" r„( ,~~~~ ~i~~f E~ ~~~~,~ 1 SECTION 2 SCOPE OF WORK (SERVICES) The Contractor will provide intake and assessment services, 7 Habits of Highly Effective Families Training, Family Team Conferencing Services and home visits for up to thirty (30) youth and their families in accordance with The Children's Trust Miami Beach Service Partnership Grant, dated December 1, 2007. 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 "AA, as follows: (a) Intakes and assessments of referred families at Eighty-Five Dollars ($85) per each intake for up to Thirty (30) families, for a maximum not to exceed Two Thousand Five Hundred and Fifty Dollars ($2,550); (b) Family Team Conferencing Contracts for referred families at One. Hundred Twenty-Seven ~ Dollars and Fifty Cents ($127.50) each, for up to Thirty (30) families, for a maximum not to exceed Three Thousand Eight Hundred and Twenty-Five Dollars {$3,825); (c) Facilitation of 7 Habits of Highly Effective Families Training at eighty (80) sessions at Sixty-Two Dollars ($62) per session, for a maximum not to exceed Four Thousand Nine Hundred and Sixty Dollars (($4,960); and (d) Provision of home visits for referred clients and their families at up to three (3) visits each for up to Thirty (30) families at Sixty-Two Dollars ($62) per visit, for a maximum not to exceed Five Thousand Five Hundred and Eighty Dollars ($5,580). 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 Sixteen Thousand Nine Hundred and Fifteen Dollars ($16,915). 3.2 INVOICING Contractor shall submit monthly invoices, a Monthly Progress Report, and accompanying Monthly Progress Submissions Checklist & Summary Form, 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 L. Ruiz, Division 2 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. 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 2$7.133(3)(a) Florida Statute an 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 (TERMI The term of this Agreement shall commence upon execution of this Agreement by all parties hereto, and shall terminate on May 31, 2008. 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 May 31, 2008. 4.5 INDEMNIFICATiOIy, 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 3 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. #o 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 liabili#y 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 4 NOTWITHSTANDING SECTION 4.6.4, THE CITY MAY ALSO, FOR tTS 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 EFFECTNE 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 70 ITS PROVISION OF THE SERVICES CONTEMPLATED IN SECTION 2 AND IN EXHIBIT "A", SHALL BE PROMPTLY ASSEMBLED AND DELNERED TO THE GITY, 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 Insoivencv 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. S 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. 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 REQUIREAAENTS 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 shat( 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. 6 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 prive, Miami Beach, Florida 33139. The Contractor is solely responsible for obtaining and submitting a!I 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 Vt" 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 7 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 wi#h 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 status, or physical handicap. The Contractor shall take a~rmative 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 i# 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. 4.1T NOTICES All notices and communications relating to the day-today 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 execu#ion of this Agreement by the parties and prior to commencement of the Services. 8 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 shalt be addressed as follows: TO CONTRACTOR: Ayuda, Inc. Attn: Luis De Jesus, President 1106 Normandy Drive Miami Beach, Florida 33141 (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. J~1RI~DICTI0NNENUE 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, EXPRESSLY WAIVE ANY RIGHTS EITHER PAR JURY OR ANY CIVIL LITIGATION RELATED T0, AGREEMENT. 4.19 ENTIRETY OF AGREEMENT CONTRACTOR AND CITY TY MAY HAVE TO A TRIAL BY OR ARISING OUT OF, THIS 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. 9 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 Gity 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 limi#ed to a maximum amount of $1,000. 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. FOB CITY OF MIAMI BEACH, FLORIDA ATTEST: Ql City Glerk Robert Parcher FOR CONTRACTOR: ATTEST: ~y' Secretary ~ SAN ~evG5vS Print Nam Corporate Seal Mayor Matti Herrera Bower Ayuda, Inc., A Florida Corporation 11 APPROVED AS TO FORM & LANGUAGE .& FOR EXECUTION Luis De Jesus EXHIBIT "A" "SCOPE OF SERVICES" The Contractor agrees to provide the following services. _ _ Serv_ice_ _ __ __ __ Docum_entatio_n of Service _ r Intake & Assessment ;Form la ~~ ss University Intake 8~ Assessment r r------ - ___ _ __ ~ i Family Team Conferenang !Completed Family Team Conferencing Contract j 7 Habits of Highly Effective ~ om leted Attendance Roster attached for each famil i Families Training _ _______ _-__ ___~ Attendingeach session__________ ______ t--- ----------- +------- Home Visits & Appropriate I Client Contact Report (attached) and Services Referral Referrals (Form (attached) for each service sought 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, quarterly and annual progress report • Timely and accurate submissions of financial reports • Delivery of contracted service units • Promotion of the Miami Beach Service Partnership • Attendance at Miami Beach Service Partnership Governing Board and related City committee(s) meetings In addition, the Contractor agrees to allow the City to post a link to the Contractor's home website as well as enable a link from the Contractor's website to the City's website. Service Deliverables Intake $ Assessment Fami~ Team Conferencing ___ 7 Habits of Highly Effective Families Training____-_______ Home Visits & Appropriate Referrals Unit of Service 1 f_or each. ofd to 30~-south ___ 1 far each of up to 30~outh _ 80 evening sessions serving up to 30 families _ _ _ Up to 3 for each of up to 30 referred youth and their families Location Client Home Biscayne Elementary Client Home The Contractor further agrees to address the following agency issues that were identified via the Agency Evaluation conducted by Dr. Martell Teasley of Florida State University and delineated in the report, "Evaluation for Participation in Success University: Miami Beach Service Partnership," dated October 2007. 12 These include: • Providing greater emphasis on developing aggregate client data • Improving the tracking of outcomes for long-term clients • Providing greater focus of client pre-testing prior to providing program interventions to clients • Identifying methods for determining the severity of client problems and subsequent service needs • Improving the tracking of client outcomes across all intervention programs 13 Exhibit "A" Attachments Intake & Assessment Form Family Team Conferencing Contract Training Attendance Roster Client Contact Report Referral Form Partner Performance Ratings Data Tracker #: Household Demographics Youth Client Name First Middle Last Client Address Apt. # Zip Code Home Telephone Cellular Telephone Alternate Telephone Sex ^ Male ^ Female ^ Transgender Race ^ White, Caucasian ^ Black, African American ^ Asian ^ Alaskan Native ^ American Indian ^Muhi-racial ^ Other (Indicate) Ethnicity ^ Hispanic ^Non-H ispanic Marital Status ^ Single ^ Married ^ Divorced ^ Separated ^ Widowed ^ Domestic Partnership ^ Other (Indicate) Family Unit ^ Married Couple ^ Married Couple w/Children ^ Unmarried Couple wlChildren ^ Single ^ Single Parent w/Children ^ Domestic Partnership w/Children ^ Other (Indicate} Client Date of Birth Client Place of Birth Client Social Security # Client School ID#: Client Status ^ US Citizen ^ US Resident Alien Registration # ^ Work Permit Work Permit # ^ Visitor's Visa Visa # ^ Student Visa Visa # ^ Other (Indicate) Mother's Name Date of Birth Social Security Number Driver's License Number Father's Name Date of Birth Social Security Number Driver's License Number Step-Mother's Name Date of Birth Social Security Number Driver's License Number Step-Father's Name Date of Birth Social Security Number Driver's License Number Legal Guardian INon-~arentl Date of Birth Social Security Number Driver's License Number Client Primary Language ^ English ^ Spanish ^ Haitian -Creole D Portuguese ^ Russian ^ Other Household Members Date of Birth Relation to Client ^ Parent ^Step-Parent ^ Significant Other to Parent ^ Parent ^Step-Parent ^ Significant Other to Parent ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other ^ Child ^ Adult Relative ^ Other Miami Beach Service Partnership/ Universal Intake & Referral form May 2007 Household Financial Profile Household Income Income Source Detail Monthly Benefit/Earnings ParentlGuardian Employment Earnings Employer: Parent/Guardian Employment Earnings Employer: S ouse/Significant Other Earnin s Employer: Parent SSA Benefits ^SSI ^SSDI ^ SS (retirement) Spouse/Significant SSA Other Benefits ^SSI ^SSDI ^ SS (retirement) Spouse/Significant Other Pension Source: Client SSA Benefits ^SSI ^SSDI ^ SS (retirement) Dependent SSI Benefits Dependent: De endent SSI Benefits Dependent: De endent SSI Benefits Dependent: De ndent SSI Benefits Dependent: Household Food Stamp Benefits # of Persons Covered: Temporary Aid for Needy Families Date of Expiration: General Public Assistance Source: Expiration: Child Support Dependent: Child Sup ort Dependent: Child Sup ort Dependent: Child Su ort Dependent: Child Sup ort Dependent: Alimony Source: Alimony Source: Alimon Source: Investment Income Source: Investment Income Source: Other: Source: Other: Source: Other: Source: Monthly Household Income Total - ~ .x-= ;i. Household Expenses Expense Source Detail Monthl Ex ense/Cost Housin ^ Rent ^ Own ^ Lives w/Others ^ Other Utilities ^ Electricity ^ Natural Gas Utilities ^ Telephone ^ Cellular Utilities ^ Cable ^ Satellite Service Utilities ^ Internet Provider Household Insurance ^ Renters ^ Property Insurance Medical Insurance ^ MedicaidtMedicare ^ Private Medical Expense ^ Co-pay ^ Prescription ^ Medical Care Food Ex nse WaterlSanitation Vehicle Loan/Lease Expense ^ Own ^ Lease Vehicle Insurance Vehicle Operatin Cost ^ Gasoline ^ Repairs Transportation Expense ^ Public Transportation ^ School Transport Child Su port/Alimony ^ Child Support ^ Alimony Other Source: Other: Source: Other Source: Monthly Household Expenses Miami Beach Service Partnership/ Universal Intake & Referral Form May 2007 Adult Services Profile Current Services Matrix Please indicate all services received/obtained by the adult members of the client's household. Be sure to include the provider where indicated. Service Received Parent: spouse~significant other: Other: Other: Adult Day Care Counseling Services Disability Benefits Educational Services Elder Services Food Stamps r,~ ~ , ~r Food Subsidy Home Care Assistance Housing Assistance Legal Assistance Medicaid ~ 1 Y ~ .~ ~ ~ ~;ff 1~ t ~n~_r +.f 4~ ~ Medicare ~ ; ~+r _:. t H, i r z r~ 'i e ~t;~s ~ . is t r, ; a,. Rehabilitation Services Survivors Benefits SSA ... :, TANF Transportation Services Utility Assistance Vocational Training Other: Other: Other: Other: Miami Beach Service Partnership/ Universal Intake & Referral Form 3 May 2007 Adult Services Assessment Employment Profile Is Father/Stepfather/Male Guardian currently employed? ^ Yes ^ No ^ Disabled If Yes: Current Employer Job Title Is Mother/Stepmother/Female Guardian currently employed? If Yes: Current Employer Job Title ^ Yes ^ No ^ Disabled Housing Assessment Housin Unit ^ Apartment ^Single-Family Home ^ Mobile Home ^ Other # of Bedrooms ^ Studio ^ 1 ^ 2 ^ 3 ^ 4 ^ 5 or more # of Persons in Household ^ 1 ^ 2 ^ 3 ^ 4 ^ 5 ^ 6 ^ 7 or more Housing Adequacy Are there more than two people per bedroom? ^ Yes ^ No Does housing meet safety requirements? ^ Yes ^ No Has client moved more than twice in the past 12 months? ^ Yes ^ NO Daes client spend more than 50% of income for housing? ^ Yes ^ No Is client at-risk of losing current housing? ^ Yes ^ No Health Assessment Service Inquiry Father/Male Guardian: MotherlFemale Guardian: SpouselSignificant Other: Other: When was your last Medical: Medical: Medical: Medical: visit with a doctor? Dental: Dental: Dental: Dental: E e: E e: E e: E e: Other: Other: Other: Other: Have you been ^ Yes ^ Yes ^ Yes ^ Yes hospitalized in the ^ No ^ No ^ No ^ No ast 12 months? ^ Don't Know ^ Don't Know ^ Don't Know ^ Don't Know Do you currently have ^ Yes ^ Yes ^ Yes ^ Yes any medical ^ No ^ Na ^ No ^ No roblems? ^ Don't Know ^ Don't Know ^ Don't Know ^ Don't Know DO you have any ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare ^ Medicaid ^ Medicare ^ Medicaid ^ 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? ^ Don't Know ^ Don't Know ^ Don't Know ^ Don't Know Do you have a history ^ Yes ^ Yes ^ Yes ^ Yes of alcohol or drug ^ No ^ No ^ No ^ No abuse? ^ Don't Know ^ Don't Know ^ Don't Know ^ Don't Know Are you currently ^ Yes ^ No ^ Yes ^ No ^ Yes ^ No ^ Yes ^ No using? if yes: If yes: If yes: If yes: Substance of choice: Substance of choice: Substance of choice: Substance of choice: ^ Alcohol ^Gocaine ^ Alcohol ^Gocaine ^ Alcohol ^ Cocaine ^ Alcohol ^ Cocaine ^ Marijuana ^ Heroin ^ Marijuana ^ Heroin ^ Marijuana ^ Heroin ^ Marijuana ^ Heroin ^ Other ^ Other ^ Other ^ Other Narrative of health assessment. Miami Beach Service Partnership/ Universal Intake & Referral Farm 4 May -2007 Youth Services Profile Current Services Matrix Service Received Youth Client or Child #1: Child # 2: Child #3: Child # 4: Day Care/ Childcare Counseling Services Disability Benefits ., .,: ~ '' Educational Services Food Stamps Food Subsidy Home Care Assistance Legal Assistance Medicaid Medicare 4 \ 1 Y .~, yh«. ~i5 ~,~ h~5 Rehabilitation Services Survivors Benefits SSA ~{ 4 ~i,s n - a T TANF Transportation Services Tutoring Vocational Training Other: Other: Other: Narrative of service history. Miami Beach Service Partnership/ Universal Intake & Referral Form May 2007 Youth Assessment Risk Factor Assessment Factor Youth Client or Child #1. Child is pertorming ^ Yes ^ No below school level ^ N/A ^ Unknown Child has been ^ Yes ^ No diagnosed with a ^ N/A ^ Unknown learnin disabili Child is having ^ Yes ^ No behavior problems in ^ N/A ^ Unknown school Child has a poor ^ Yes ^ No attitude towards ^ N/A ^ Unknown school Client attends school ^ Yes ^ No with hi h mobili rate ^ N/A ^ Unknown Child has chronic ^ Yes ^ No medical roblems ^ NIA ^ Unknown Child has been a ^ Yes ^ No victim/witness of ^ N/A ^ Unknown domestic violence Child has moved more ^ Yes ^ No than twice in the past ^ N/A ^ Unknown 12 months Child has experienced ^ Yes ^ No economic deprivation ^ N/A ^ Unknown in the ast 12 months Child lives in asingle- ^ Yes ^ No arent home ^ N/A ^ Unknown Child has sibling who ^ Yes ^ No dro out of school ^ N!A ^ Unknown Child or sibling is ^ Yes ^ No involved in a an ^ NIA ^ Unknown Client is exposed to ^ Yes ^ No drug use in home or ^ N/A ^ Unknown nei hborhood Child lives in high ^ Yes ^ No crime area ^ NIA ^ Unknown Child has a parent or ^ Yes ^ No caregiver who has ^ N!A ^ Unknown been arrested Child has access to ^ Yes ^ No after-care services or ^ NIA ^ Unknown adult su rvision Child is experiencing ^ Yes ^ No n lect ^ N/A ^ Unknown Child has been ^ Yes ^ No ,involved in the juvenile ^ NIA ^ Unknown '~ 'ustice s stem Child has missed 10 or ^ Yes ^ No 'more school davs ^ N/A ^ Unknown Narrative of identified risk factors. Child # 2: ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ N/A ^ Unknown ^ Yes ^ No ^ N!A ^ Unknown ^ N/A ^ Unknown ^ NIA ^ Unknown ^ Yes ^ No O NlA ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ N!A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown Child # 4: ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ NlA ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ NIA ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown ^ Yes ^ No ^ N/A ^ Unknown Miami Beach Service Partnership/ Universal Intake & Referral Form 6 May 2007 Youth Services Profile Health Assessment Service Inquiry Youth Client or Child #1: Child # 2: Child #3: Child # 4: Last visit with a doctor Medical: Medical: Medical: Medical: Dental: Dental: Dental: Dental: E e: E e: E e: E e: Other: Other: Other: Other: Has child been ^ Yes ^ Yes ^ Yes ^ Yes hospitalized in the ^ No ^ Na ^ No ^ No ast 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 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? ^ Private ^ Private ^ 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 Academic Assessment Service Inquiry Youth Client or Child #1: Child # 2: Child #3: Child # 4: School Attended ^ Biscayne Elementary ^ Biscayne Elementary ^ Biscayne Elementary ^ Biscayne Elementary ^ Fienberg Fisher K-8 ^Fienberg Fisher K-8 ^Fienberg Fisher K-8 ^Fienberg Fisher K-8 ^ North Beach Elementary ^ North Beach Elementary ^ North Beach Elementary ^ North Beach Elementary ^ South Pointe Elementary ^ South Pointe Elementary ^ South Pointe Elementary ^ South Pointe Elementary ^ Nautilus Middle ^ Nautilus Middle ^ Nautilus Middle ^ Nautilus Middle ^ Miami Beach Senior ^ Miami Beach Senior ^ Miami Beach Senior ^ Miami Beach Senior ^ N/A ^ NIA ^ N/A ^ NIA Grade ^ Pre-K ^ K ^ 1 ^ Pre-K ^ K ^ 1 ^ Pre-K ^ K ^ 1 ^ Pre-K ^ K ^ 1 ^2 ^3 ^4 ^2 ^3 ^4 ^2 ^3 ^4 ^2 ^3 ^4 ^5 ^Ei ^7 ^5 ^6 ^7 ^5 ^6 ^7 ^5 ^6 ^7 ^8 ^9 ^10 ^8 ^9 ^10 ^8 ^9 ^10 ^8 ^9 ^10 ^11 ^12 ^11 ^12 ^11 ^12 ^11 ^12 School Absences Current Year Current Year Current Year Current Year Prior Year Pricer Year Prior Year Prior Year Grade Point Average Current Year .Current Year Current Year Current Year Prior Year Prior Year Prior Year Prior Year ESE Status ^ Specific Learning Disabled ^ Specific Learning Disabled ^ Specific Learning Disabled ^ Specific Learning Disabled ^ Speech Impaired ^ Speech Impaired ^ Speech Impaired ^ Speech Impaired ^ Emotionally Handicapped ^ Emotionally Handicapped ^ Emotionally Handicapped ^ Emotionally Handicapped ^ Educable Mentally Handicap ^ Educable Mentally Hantlicap ^ Educable Mentally Handicap ^ Educable Mentally Handicap ^ Language Impaired ^ Language Impaired ^ Language Impaired ^ Language Impaired ^ Gifted ^ Gifted ^ Gifted ^ Gifted ^ Other Health Impaired ^ Other Health Impaired ^ Other Health Impaired ^ Other Health Impaired ^ Severely Mentally Handicap ^ Severely Mentally Handicap ^ Severely Mentally Handicap ^ Severely Mentally Handicap ^ Trainable Mentally Handicap ^ Trainable Mentally Handicap ^ Trainable Mentally Handicap ^ Trainable Mentally Handicap ^ Autistic ^ Autistic ^ Autistic ^ Autistic ^ Hospital/Homebound ^ Hospital/Homebound ^ Hospital/Homebound ^ Hospital/Homebound ^ Deaf/Hard of Hearing ^ Deaf/Hard of Hearing ^ Deaf/Hard of Hearing ^ Deaf/Hard of Hearing ^ Orthopedic-Impaired ^Orthopedic-Impaired ^Orthopedic-Impaired ^Orthopedic-Impaired ^ Developmentally Delayed ^ Developmentally Delayed ^ Developmentally Delayed ^ Developmentally Delayed ^ Visually Impaired ^ Visually Impaired ^ Visually Impaired ^ Visually Impaired ^ Profound Mental Handicap ^ Profound Mental Handicap ^ Profound Mental Handicap ^ Profound Mental Handicap Miami Beach Service Partnership/ Universal Intake & Referral Form May 2007 Miami Beach Service Partnership Authorization for Release and Exchanue 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. ^ City of Miami Beach ^ Jewish Community Services • Junior Achievement ^ Miami Beach Community Health Center ^ Miami-Dade County Public Schools ^ National Foundation for Teaching Entrepreneurship ^ Teen Job Corps ^ Unidad/Miami Beach Hispanic Community Center 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 Informa#ion ^ Education/Training/SkiNs Background ^ Employment Background & Information ^ Support Service Information ~ndud'mg entitlements & current ~~> ^ 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. 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 Witness Signature Date Wdness Name -Printed Client Name Miami Beoch Service Partnership/ Universal Intake & Referral Form 8 May 2007 Miami Beach Service Partnership Project INVITED PARTICIPANTS OF THE FAMILY GROUP CONFERENCE (FGC) Youth's Name: Student #: Parent's/Guardian's Name: Preferred Location, Date & Time of FGC: Mother: Father: Gaurdian: Care Giver: ...Invited Partici ants Continued i:,x~aop-rv~;nlmvrt~~uvi PAge Of CODES: C=Attendance Confirmed N=Unable to Attend A a 8 ~~ ~ ~ .. ~ ~~ ~~ ~° ~ as a ~ ~~ ~ o ~~ ao ~ ~ ~~ ~ ~ .a ~, w ar a~ .~ e~ .~ W N d a~ e~ z w 0 ~ a o F a v w o W U U ~ U U ~i a 0 v N W A .-+ O F H ~I N U d W r, GW7 a w W U x° U EH 4 "t! O v N A W ~~ ~o ti U v ~ ~ N I N I N N ( N I N I N I N N N M M M N a a w w U O x U F+ lM+~ Q M M .. W E-+ d A a w V „a9 W z ~ o .., w ~ ~ a a a v ~~ w z x H 0 U"~ W U Z Q V F z w a H t!1 W V 4 V a~ +~ A ~.7 W a~ Z a 0 N 4r O N a~ ado a 0 z w i/~ {~i U O ~••~~` =Strong - --/--/--/--/-- =Stressed ---------- -Weak - - =Absent Natural Support Map O =Female =Male Q =Provider Name T e of Su ort/Relationshi s, etc. T:CHOICES/MB2007trngEcomap ECO-i?Z~lp An ecomap is structural assessment tool used to visualize family member's contact with the larger systems In our case, with the child(ren) it is used to illustrate the current relationships and systems of support - In pictorial for, outlines relationships between individuals; - The flow of resources and support (in & out) can be shown. - Shows dynamics between the subject child and their family support system/agency support etc... 1. Solid' lines ( )indicate strong relationships (the thicker the line the stronger the tie); 2. Dotted lines (- - - - - -) indicate weak relationships; 3. Crossbars (~ /-/-~/) on the line indicate stressful relationships; 4. Absence or distance of lines ( ;- .)indicate no or distant connection; S. Arrows signify energy or resource flow (~.~); 6. Q=female; ~ =male; Q=provider; T/7A CI-IOICES:MB2007tTrngEcomap G :a ~~ .~, w .. d F .. -1 b ~v v ~1 U .~ V ~1 ~+ ~ ~ ~ ,~. ~ ti d w a O p~ t, b~ 0 ~ V2 `. ~ ~ ~ _ ~~ ~ ~AV a; d d a~ L .C 3 a ~• aao `S 3 ~~ view ~ c• ~ o .~ ~ ~~ ~E ~ ~ ~~ ~- u o ~ da m p ~6 ~ w~u 3~aa 3~aa 3~aa 3 a a ~, :~ ~~ ~ a z a ,~-, .~. ~ ,w R., a.. o ~ ~~ ~ ~" 0 q ~ ~n ~ 0 ~'o~ ~ ~ Ao W U c• ~. u ao "d d ~ . ° s O b O O ~ '" C~ ~° ~~ ~~ .~ ~ t, D ~' a C a~''S ~ '~ O ~~ 3~aa r~ ,~ a s 3~ a a 3 ~., a s 3~ a a :.. ~' H a~ z ~ a 8 °° •tL ~ d a d,. a ~ ~~ 0 ~o in ... 0 ~'o a A ~ V a• ~. ~ ~ °~ "p e a d ~ y~ ~`• b a~~ aA o 0 o~ v ~~ i m c ~~ :~ ~E a4 ~ w o ,~ ,°«3 tY" ~~ a ~ ~~ a~-~ 3•-aa 3•-aa 3•-aa 3•~aa y i~ a . ~ ~ ~ a ..,, i~ O 'W ^' ~ wa ~. ^ a. V ^~ v .~ tQ .~ d 4 ~. m W ~. C .~ •L ~.,,r 0 a Y C N F- .~ .~ N c~ m a H '~ 4 .~ w a~ c 0 s m m I- ~.. G m a Z Miami Beach a1~~,,~~ ~ Success University Initiative Training Attendance Roster Client: Reporting Period ^.January 2008 ^ March 2008 ^ May 200$ ^ December 2007 ^ February 2008 ^ April 2008 ^ dune 2008 Reporting Date: Person Submitting Report: Title: Signature: Attendance Record Family Team Conferencing 7 Habits of Highly Effective Families D Client D Foundation & Habitl D Parent/Caregiver D Habits 2 & 3 ~ Parent/Caregiver D Habits 4 & 5 O Sibling O Habits 6 & 7 O Sibling D Client O Sibling D Parent/Caregiver D Sibling D Parent/Caregiver O Other D Sibling D Other ~ Sibling D Other D Sibling D Other O Sibling D Other D Other D Other D Other Comments/Observations: Miami Beach Success University Initiative Client Contact Report Client: Reporting Period: ^ January 200$ ^ March 2008 ^ May 2008 Reporting Date: ^ December 2007 Person Submitting Report: ^ February 2008 Title: ^ April 2008 Signature: ^ June 2008 Purpose of Contact: ^ 7 Habits Training Method of Contact: ^ Intake & Assessment D Home Visit ^ Telephone ^ Home ^ Family Team Conferencing ^ Service Follow-u ^ In-Person (Service Site) ^ Other Home Needs Assessmen t Family Health Physical Health Emotional Health O Client/Family healthy O Client/Family report good family relations O Client/Family in need of health services O Client/Family report relational problems - - Referral i~ -Identify and explain in Summary -.Referral, if a ro riate t~ Home Stability Financial Housing O Family is financially stable O Housing is appropriate for family O Family in need of financial assistance - ©Housing is inappropriate for family -Identify and explain in Summary because of cost, size or quality - - Referral 1~- -Identify and explain in Summary - Referral ib- !'tease provide a narrative summarizing contact client feedback regarding services provided. ress or family. Indicate concerns, areas 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 ^ Black, Non-Hispanic ^ His anic ^ Other Address2ip Code Home Telephone/ Work Telephone Marital Status Housing Status ^ Single ^ Married ^ Divorced ^ Own ^ Rent ^ Live w/others ^ Se arated ^ Domestic Partnershi ^ Other ^ Homeless ^ Other Others in Household Household Income ^ Child ^ Adult ^ Employment - $ ^ Child ^ Adult ^ SSA ^ SSI ^ SSDI - $ O Child ^ AduR ^ 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 ^ Biscayne Elementary ^ Fiemberg Fisher K-8 Center ^ 9 ^ 10 ^ 11 ^ 12 ^ North Beach Elementary ^ North Beach Elementary ^ Nautilus Middle ^ Miami Beach Senior High M-DCPS ID # Services Histo Food Stamp Recipient ^ Yes ^ No ^Pendin Section 8 Recipient ^ Yes ^ No ^Pendin SSA Benefits Medicaid/Medicare Recipient ^ Benefd Amount $ ^Pendin ^ Yes ^ No ^Pendin Current Service Providers Current Service Needs ^ ASPIRA ^ AYUDA ^ Child Care After Care ^ Boys 8 Girls Club ^ Catholic Charities ^ Disability Benefits O CAA ^ City of Miami Beach ^ Disability Services ^ DCF ^ Douglas Gardens ^ Educational Services ^ HACOMB ^ JCS ^ Employment Assistance ^ Legal Services of Miami ^ Lutheran Services ^ Food ^ Miami Beach CHC ^ M-Dade Hous. Auth. ^ Housing Services ^ SSA ^ Teen Job Corps ^ Legal Services ^ Veteran's Affairs ^ Volunteers of America ^ Medical Services ^ UNIDAD ^ Substance Abuse Services ^ Other ^ Youth Intervention Services ^ Other ^ Youth Prevention Services ^ Other ^ 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 Child Care/Aftercare Services ^ Child Care ^Ayuda, Inc. ^ Aftercare ^Ayuda, Inc. ^ Boys/Girls Club ^ MB PAL ^ MB Recreation Clothin Services ^ Clothing ^ Neat Stuff ^ Suited 4 Success Counselin Services ^ Youth ^Ayuda, Inc. ^ JCS #1 ^ MBCHC D Adult ^ t~uglas Gardens ^ JCS #1 ^ Family ^Ayuda, Inc. ^ JCS #1 Elder Services ^ Referral ^Ayuda, Inc. ^ JCS #! ^ DMS/Adutt Day Caro ^ LHANC - MB ^LHANC - RT ^ MB - OC5 ^ UNIDAD ^ Home Care ^ NID -Human Services Employment As sistance D Child Care D Ayuda, Inc. D Aftercare D Ayuda, Inc. ^ BoyslGiris Club D MB PAL ^ M8 Recreation Financial Assistance D Cash ^ Culmer Center Assistance D Edison/Little River Food Assistance ^ Emergency ^ Emergency Food Food ^ Food Stamps ^ Food Stamps ^ Discount Food ^ Discount Food Housin Assistance ^ Emergency ^ MB -0CS shelter ^ Affordable ^MBCDC Housing ^ Transitional ^ Douglas Housing Gardens/Ma air Other Services ^ ^ ^ ^ Housing Assistance ^ Emergency ^ MB - OCS Shelter ^ Affordable ^MBCDC Housing ^ Transitional ^ pouglas Housing Gardens/Ma air Le ai Services ^ Disability O Legal Services Benefits ^ Immigration ^ FIAC Services ^UNIDAD ^ --andlwd/Tenant ^ L al Services Medical Services _ ^ Medical .~ _ ^MBCHC _._ Services ^ Dental Services ^MBCHC ^ UNIDAD ^ Mental Health ^ Douglas Gardens CMHC ^ JCS #1 Rent Assistance ^ Rent ^ CAA #! Assistance ^Culmer Ctr. ^ Edison/Little River Center Substance Abuse Services ^ Detox Servuces ^JMH Crisis ^ Addiction Services ^ Central Intake Transportation Assistance ^ Disabled ^ Transit ^ Veterans Agency ^ Elder ^ STS Utilities Assistance ^ Elder Program ^ EHEAEP ^ Emergency ^Culmer Ctr. Help ^ Edison/Little River Center ^ LHEAP Youth Development ^ ^Aspira AcademiclTutoring ^Ayuda, Inc. ^ BoysJGiris Club ^ MB - OCS ^ Youth D Aspira Development ^Ayuda, Inc. ^ Employment ^ CAA ~ ^ JCS #1 ^ Teen Job Co D American Veterans' Food 6632 Collins Avenue/305.867.6060 D Aspira 4100 NE 2nd Avenue/305.576.8494 D Ayuda, Inc. 1106 Normandy Avenue/305.864.2273 D Boys ~ Glris Club 1245 Michigan Avenue/305.673.7760 ^ Central Intake 2500 NW 22nd Avenue/305.638.6540 D Community Action Agency #1 6100 NW 7"' Avenue/305.756.2830 D Community Action Agency #'1 810 NW 28d' SVeet/305.638.4672 D Cukner Service Center 1600 NW 3`d Avenue/305.579.2820 ^ Dept. of Children ~ Families 945 Pennsylvania Avenue/305.535.5401 D DHS/Adult Day Care 150 - 79"' Street/305.571.4342 D Douglas Gardens CMHC 701 Lincoln Road/305.531.5341 D Douglas Gardens/Mayfair 1960 Park Avenue/305.531.5341 D EHEAEP 395 NW 1`~ Street/305.347.4685 D EdisonlLittle River Service Center 150 NW 79"' Street/305.758.9682 O Fla. immigrant Advocacy Center 3000 Biscayne BIvdJ305.573.1106 D JMH Crisis Center 1611 NW 12"' Avenue/305.355.7377 D Jewish Community Services #1 300 41 Street #216/305.576.6550 D Jewish Community Services #2 2056 N E 155"' Street/305.947.8093 D Jewish Community Services #3 Access & Referral Services/305.576.6550 D LHEAP 2902 NW 2n° Avenue/305.438.8614 D Legal Services of Greater Miami 3000 Biscayne Blvd./305.576.0080 D Little Havana/Miami Beach 533 Collins Avenue/305.532.8576 D Little Havana/Rebecca Towers 150 Afton Road/305.572.3736 D Miarrri Beach CDC 945 Pennsylvania Avenue/305.538.0090 D Miami Beach CHC #1 770 Afton Road/305.538.8835 O Unidad/Miami Beach HCC 8336`" Street/305.532.5350 D Miami Beach -Community Services 555 -17"' Street/305/6737491 ^ Miami Beach Police Athletic League 999 - 11 "' Street/305.531.563B ^ Miami Beach -Recreation 2100 Washington Avenue/305.673.7730 D Miami-Dade Hunan Services 4500 Biscayne Blvd,/305.576.2511 ^ Miami-Dade TransR 111 NW 1'' Street/305.770.3131 D St. Joseph's Church 8670 Byron Avenue/305.866.6567 D St. Patrick's Church 3716 Garden Avenue/305.531,1124 D Teen Job Corps 305.868.0635 D Temple Beth Sholom 4144 Chase Avenue/305.538.7231 ^ Other . Miami Beach Service Partnership Partner Performance Ratings Agency: ^ Aspira of Florida ^ Choices et al. Inc. ^ Jewish Community Services ^ MBCHC ^ Teen Job Corps ^ Ayuda, Inc. ^ City of Miami Beach ^ Junior Achievement ^ NFTE ^ Unidad Reporting Period: ^ December 2007 ^ February 2008 ^ Apri12008 ^ June 2008 ^ January 2008 ^ March 2008 ^ May 2008 ^ Final Report Service Cate o Performance R atin Scale Timely submission of monthly, quarterly and annual progress reports 0/20 Timely and accurate submissions of financial reports 0/20 Delivery of contracted service units 0 - 20/20 Promotion of the Miami Beach Service Partnership 0 - 20/20 Attendance at Governing Board and committee meetings 0 - 20/20 TOTAL SCORE 100 Comments: OtTice Use Only Date Posted on Website: Staff Fosting: EXHIBIT "B" INVOICING The Contractor agrees to provide the invoicing and services documentation as indicated in the Monthly Progress Report and Monthly Progress Submissions Checklist & Summary Form, as attached to this Exhibit. 14 Exhibit "B" Attachments Monthly Progress Report Form Monthly Progress Submissions Checklist & Summary m ~ ~ ~~ i ~ Miami Beach , Success Univers'~tY Initiative Monthly Progress Report Grant Number: Reporting Period: ^ December 2007 ^ January 2008 ^ February 2008 ^ March 2008 ^ April 2008 ^ May 2008 ^ dune 2008 Sub-grantee Organization: Project Director: Telephone: Reporting Date: Person Submitting Report: Title: Signature: Title: E-Mail: Population Served Population & Quantify Served: Population Check all that apply. Utilize attendance rosters and sign-in sheets as data source. ^ Youth ^ Parents ^ Extended Family ^ Others ^ Staff Allocated Budget: $ Year-To Date Spent: $ Remaining Balance: $ Current Year- Projected Month to- Date Financial Summary Current Month reimbursement Request: Services Summary Services Provided: Services Check all that apply. Utilize attendance rosters, sign-in sheets and reporting forms as data source ^ Intakes/Assessments ^ Family Team Conferencing ^ 7 Habits for Youth ^ 7 Habits for Families ^ MB Helpers Training ^ Entrepreneurship Training ^ Tutoring ^ Community Service ^ Transportation ^ Meals ^ Programmatic Management ^ Other Units Provided m i,:",F~iPJBEACH Miami Beach . Success Universit~r Initiative Monthly Progress Submissions Checklist & Summary Grant Number: Reporting Period: ^ December 2007 ^ January 200$ ^ February 2008 ^ March 2008 ^ April 2008 ^ May 2008 ^ June 2008 Sub-grantee Organization: Project Director: Telephone: Reporting Date: Person Submitting Report: Title: Signature: Title: E-Mail: Brack Up Documents Submitted P{ease include copies of pertinent documents and attach to your report/reimbursement request. ^ Case Contacts ^ Family Team Conferencing Contracts ^ Payroll Records O Pre-tests/Initial Surveys ^ Post-tests/Closing Surveys ^ Purchase Receipts ^ School Data (attendance/Grade Point Average/disciplinary referrals) ^ Sign-in Sheets/Attendance Records ^ Other ^ Other ^ Other ress Sum Please provide a narrative summarizing your organization's eltorts, concerns and programmatic observations for the reporting month. Be proactive in identifying areas that went weA as well as others that fell short of expectations.