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REQUEST FUR STATE APPROVAL OF - .
FANIILY PRESERVATiON PROGRA,M PLAN �
(80/20 Funding) , , '`•
` �'
This fiamily Preservation Program Plan(FPP)is hereby submitted for rlTxiN �.
(Indicate county name{s)and lead county if this is a muki-county plan}, for the period June 1;
1996 through May 31, 1997. The Plan includes the following:
♦ "Statement of Assurances'; ��.`
t ♦ S*.atement of which of the five(5)required FPP services will be provided or purchased ;::r,�`�
and a list of county optional services to be provided or purchased; i.e., County
Designed and/or Transition Service; • ,
♦ Completed program description of each proposed"County Designed Service"; ;
♦ Completed pro�ram description of each proposed"Transition Service;"
♦ Completed"Information on Fees"form;
♦ Completed"Direct Service Delivery"form; `
♦ Completed"Purchase of Service Delivery"form;
• Completed"Overhead Cost"foim;
♦ Completed"5ummary Sheet By Jndividua]Service"form; �?'
♦ Completed"Finaf Budget Page"form; �
♦ Completed"State Board Summary". .
This Family Preservarion Pro�am Plan has been developed in accordance with State Department ,
ofHuman Services rules and is hereby submitted to the Colorado Department ofHuman Services,
Division of Child Welfare Services for approval. If the enclosed proposed FPP Plan is approved,
the plan wi�l be administered in conformity with its provisions and the provisions of State �:•�'
Department ruies. f
�
The person who will act as primary contact person for the FPP Plan is KATE JANGULA �
and can be reached at telephone number��ol 920-5350 j
If this pl is proposed by two or more counties, the required signatnres below are to be �
� completed ch county,as propriate. Please attach an additional signature age as needed.
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�gnat re,D C R,C TTY DEPARTMENT OF SOCIAL SERVICES DATE
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Sig ture,CHAIR,PLACE IQI'ALTERNATIVES CO�R�TSSION DATE
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/�'�ature,CHAFf�BOARD OF COUNTY COn�IltiIISSIOI�'ERS ATE •
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FANIILy PRESERVATION PROGRAM � ;. -
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V
CORE SERVICES PLAN �i'�..�.
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� FY1996-97 ,,
FOR "�
-
PITKIN
� COUNTY(�S}
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REQL�ST FOR ST�.TE;�PPROV�.I.,OF �
F�'��.X PRESERVATION PAOGR L1�i PZ..�V "`.
Famih•Issues Cash Fund(FICF) ' :;�
(100%Funding) � -.
This Family Presen•ation Proeram Plan(FPP)is hereby submitted for PiTKi:t
(Indicate county name(s) and lead counrv if this is a multi-county plan), for the period June I,
1°96 throush�4ay 31; 1997.The Plan inc[udes the foliowing:
.. . ..`,Y. �'
♦ Statement of Assurances; .
♦ Stacement that the five(�)required FPP services will be provided or purchased and a � "
list of countt� optionat serc�ices to be provided or purchased; i.e., Counn• DesiQned '
and/or Transition Service; `
♦ Compleced proeram description of each proposed"County Desi�ned Ser�ice'; ;
♦ Completed"Information on Fees"form;
♦ Completed"Direct Service Delivery"form;
♦ Completed"Purchase of Service Delivery"form; Q
♦ Completed"�verhead Cost"form;
• Completed"Summary Sheet By Individual Senice"form; '!
♦ Completed"Final Budget Pase"form;
♦ Completed 100%FICF Summary Form.
This Family Preservation Pro�am PIan has been developed in accordance with State Depar[ment
of Human Services rules and is hereby submitted to the Colorado Department of Human Services, ;.,,
Division of Child Welfaze Services for approval. If the enclosed proposed FPP Pian is approved, +
the p(an witl be admuustered in conformity with its provisions and the provisions of State
Department rules.
The person who will act as primary contact person for the FPP Plan is KATE JANGULA ,and can
be reached at te3ephone number 874 920-5350
If this plan is proposed by two or more counties, the required si�atures below are to be
completed by e'ch councy,as appropriate. �ttach an addiuonal signature pase as needed.
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'_ a ur DIIZECTO COU� DEPART�NT OF SOCI.4I.SER��SCES DATE
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$iexature,CH.-1II�BO.aRD OF COLITY COVLNIISSIOti-ERS ! ! DATE •
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REQliEST FOR STATE aPPi20�:aI.OF -- .
F.�:tiiII,Y PRESER��ATIO\'PROGR�vI PLA� ��.;., .�
(80/30 Funding) % 1.
. .�.
Tlus Famity Preservation Proeram Plan(FPP)is hereby submitted for PITKIN •
(Indicate county name(s) and]ead county if this is a multi-county plan), for the period June 1, �:`�.
1996 chroush Viay 3], 1997. The Plan includes the iollowin�:
♦ `Sta[ement of Assurances'; ,:��>.
♦ Statement of which of the five(�)required FPP services wiil be provided or purchased
and a list of county optianal services to be provided or purchased; i.e., Councy � r
Designed andlor Transition Service: ��,'�
♦ Completed pro�ram description of each proposed"Counry Desi�ed Senice'; �:; "
♦ Completed pro�ram description of each proposed"Transition Sen�ice;' �
♦ Completed"Information on Fees"form; f°' `
♦ Completed"Direct Service Delivery•"form; r:•'
♦ Completed"Purchase of Service Delivery"form; :
♦ Completed"Overhead Cost"form;
f ;
♦ CompleLed"Summary Sheet By Individual Service"form; �;.
• Completed"Final Budget Page"form; e
�'..
♦ Completed"State Board Summary". ,,
This Family Preservation Pro�ram Pian has been developed in accordance with State Department ,:i
of Human Sen-ices rules and is hereby submitted to the Colorado Department of Human Services, '
Division of Child Weifaze Services for approval. If the enclosed proposed FPP Plan is approved, :�
the plan will be administered in confomvt�� with iu provisions and the provisions of State
Department rules.
The person who will act as primary contact person for the FPP PIan is KATE JANGULA ,
and can be reached at telephone number 8��? 920-5350
a
If this pl �s proposed by two or more counties, the required signatures below are to be
compieted� ch counn�,as propriate. Piease attach an additional si�ature age as needed.
? � �� _ �l � :
i�nat re,D C I�C i'TY DEP.�RT_�\T OF SOCL�I,SERVICES DATE �:
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Sisnature,CFL�t PLACE� \T ALTER\:aI'IV�S COvI�i Li5SI0I� DATE � •
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�nature,CK�BO�RD OF COLITY CO\�IISSIO\�RS / �D?,TE ( •
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REQLEST FOR STATE:�PPR0�:4L OF �
F.�rfII.Y PRESERVATION PROGR�VI PLA\ ?•
Famil}•Issues Cash Fund(FICF) -
, .�.
(I 00%Funding) •.
This Family Preservation Probram Plan(FPP)is hereby submitted for PITKIv
(Indicate county name(s) and lead county if this is a multi-county plan), for the period June 1,
1996 through 14ap 31; 1997.The Plan includes the following:
♦ Statement of Assurances; �
♦ Stacement that the five(5}required FPP services will be provided or purchased and a "
list of counn�optional sen•ices to be provided or purchased; i.e., Count� Desisned : '
andJor Transision Service; `
♦ Completed pro�am description of each proposed"County Designed Senice';
♦ Completed"Information on Fees"form;
♦ Completed"Direct Service Delivery"form;
♦ Completed"Purchase of Service Delivery"form; �
♦ Completed"Overhead Cost"form; `
♦ Completed"Summary Sheet By Individual Ser�lce"form;
♦ Completed"Final Budget Pa�e"form;
_ ♦ Completed 100%FICF Summary Form. '
This Family Preservation Pro�am Plan has been developed in accordance with State Deparrment
of Human Sen�ces rules and is hereby submitted to the Colorado Deparunent of Human Services, '
Division of Child Welfare Services for approval. If the enclosed proposed FPP Plan is approved, ����
the pian will be administered in conformity with its provisions and the provisions of State
Deparcment rules.
The person who will act as primary contact person for the FPP Plan is KATE JANGULA ,and can ,
be reached at telephone number B7Q 920-5950 •
If this plan is proposed by two or more counties, the required si�natures below aze to be ,
completed by e ch county,as appropriate. Attach an additional sienature pase as needed.
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�_na ur DIRECTO COLN DEP�RTtiIENT OF SOCIAI.SERVTCES DATE
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Sisaature,CH.�.Ilt,B0.4RD OF COLITY CONIMISSION�RS � � D�� ••
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REQL�ST FOR ST�TE APPROVAI.OF ,� .�
CORE SERVTCES PLA�ti ' �•
Familv Issues Cash Fund(FICF) „�.1 -�
- �.;
(]00°�o Funding) -
This Core Senices Plan is hereby submitted for PITKIN (Indicate county
name(s)and lead county if this is a muiti-counn�plan), for the period June 1, 1996 through May ��
31, 1997.The Plan includes the following: J, �
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♦ Statement of Assurances;
♦ Statement that the Core SenRCe of Vlental Health will be purchased from the vlencal `. � '
Health Center servin�the region or area unless the needed Mental Health Senice is � '
not available from the vlental Health Center or unless the county was approved to `
grandfather in providers in FY 199�-96; -
♦ Statement that the Core Service of DruelAlcohol will be purchased from either the �`
local AD AD certified contractor or ADAD certified provider; �:
♦ Completed program plan for each Core Service to be provided; � ;
♦ Completed"Information on Fees"form; �;'
♦ Compleced"Purchase of Service Deliven+"form; n''
♦ Completed"Overhead Cost"form; ��
• Completed"5u;nmary Sheet B��Individual Service"form; j
♦ Completed"Finai Budget Pa�e"form;and
♦ Compieted 106%FICF Summary Form. �
This Core Services Plan haz been developed in accordance with widelines provided by the State
Department of Human Services and is hereby submitted to the Colorado Department of Human
Services, Division of Child VJelfare Services for approval. If the enclosed proposed Core
� Services Pian is approved,the plan will be administered in conformity with its provisions and the
provisions of Stace Depanment rules.
The person who will act as primary contact person for the FPP Plan is KATE SANGULA ,and can 9
be reached at telephone number f 9 ijn 920-5350 •
If this plan is proposed by two or more counties, the required signatures below aze to be
completed by ach c tc,as appropriate. Attach an additional signature page as needed.
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'_ a ure,DIRECTO OUN " EP.3RT_�NT OF SOCI.AI,SERVZCES DATE �
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Sigr+ature,C�L�,BO.�RD OF COLITY COD�LVIISSIONERS / /DATE � ' -
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FA�III.I'PRESER�'ATIO�PROGRA1q PLati .�.
CORE SER�'ICES PLA\ �. :�,
STaTE1�IE1T OF ASSI:�12.4vCES
' �.;'
PITKI� County(ies)assures that,upon approval of the Family Preser�•ation Proeram
Ptan(FPP)and Core Secvices Plan,the foIIowing witl be adhered to in the implemencarion of the ��,'_
Plan: y,' �:. .
� ..::,�,.�'�:
1. Operation will be in conformity with the provisions of the PIan;
2. Operation will be in conformity with the provisions of State rules; s �
3. Family Presetvation Pro�ram and Core Services,provided or purchased,will be accessible
to children and their families who meet the eligibility criteria;
4. Operation wilt not discriminate against any individuaf on the basis of race, sex national
origin,religaon,age.or handicap who applies for or receives services throueh the Family �i�
Preservation or Core Services Pro�am; � �
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�. Services will recomize and support cultural and religious back�ound and customs of �
children and their families;
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6. �io out-of-state travel wiU be paid for with FPP or Core Services funds; '
;�
7. :�11 forms used in the completion of the FPP and Core Services plan will be State
prescribed or State approved forrns;
3. FPP FTE/Personal Services cosu authorized for reimbursement by the State Department
will be used only to pro�ide FPP Services authorized in the county(ies)' approved FPP
Plan;
9. The purchase of services wiil be in conformiry with State purchase of service rules f� •
includin�contract form,content,and monitorine requirements;and
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10. Infortnation regarding senices purchased or provided wiil be reported to the State '
Deoartment for program,statistical and financial purposes in confortnity with State rules. �
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FAMII.�'PRESERV�ITION PROGRar1 SER�TCES ,.
CORE SERVICES �,
TO BE PROVIUED/PURC��ISED :
. ;'
Place an(�)or a(P)co indicate which of the following Family Preservation Program Services will
be providedlpurchased in accordance with State Department rules: "A" indicates currently
a�•ailable to clients, "P" indicates that the service has pre��ously not been available to ctients;
however,the county plans to purchaselpro»de in 96-97.
� :
A Home Based Intensive Family Intervention Service (Staff Manual V"olume 7, �
7.503.61) ' - -
A Intensive Family I'herapy Service(StaffManual;Volume 7,7.50�.62)
P Sexual Abuse Treatment Service(Staff Vlanual,Volume 7,7.503.63)
_ Day Treatment Service(StaffManual,Volume 7,7.503.64)
A Liie Skills Service(StaffManual,Volume 7,7.503.65)
Check which of the followin� apply and that will be purchased in accordance with State
Depaztment guidelines:
X The Core Service of�Iental Health will be provided by the ASPEN COUNSELING CENTER
Mental Health Center. !:
_ The Core Service ofMental Health will be provided by another provider
_ The Core Service of DniJAlcohol Treatment will be provided by a cerrified
ADAD contractor.
x The Core Service ofDni�/:1lcohoi Treatment wiIl be provided by a cem5ed
ADAD provider.
List counry optional services of"County Designed Service"which will be provided/purchased in
accordance with State Department rules(Staff Vfanuai Volume 7.503.66):
Lisi Transition Service(s)which will be provided/purchased in accordance with State Department
rules(Staff tifanuaf, Voiume 7, 7.503.57).The ser�ice must have been approved in FY 94-9� & `
9�-96 in order to be provided in FY 96-97.
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�NT.ai,HE?.LTH SER�ZCE L��OR1LaTTOti `� Y
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Mental Heahh Sen•ice Provider\zrne(s) ASPE� COUNSELING CENTER �.�
Mental health services are approved as a part of the county(ies)' FPP/Core Services Plan on an , '� '
annua]basis. Presently,for a mental health serv•ice to be ea�tended beyond one yeaz,this portion
of the plan must be submitted and approved annually by the State Deparcment.
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The informatioa lisied below is to be submitted in the form of a�Iental Healih Services Plan and
is to be included in the County(ies)'Family Preservation Proeram/Core Services Plan. "?�"
1. Elieible Population + - "
A.� Each child shall meet the criteria of. •
1. Colorado's out of home placement criteria
2. Cirild is at imminent risk of out-of-home placement
` 3. The county defined child population,and
4. A manaeeable level of risk of harm to the child
B. Children may also meet the followins criteria:
� 1. Children in out-of-home placement in need of an expedited procedure for �'
pennanent placement.
2. Ineli�ble Pogulation =
A. Children who meet the above criteria and are Medicaid eli�ble are not eligible for
these services �
3. Types of Service Provided ' `'
A. Psychological evaluation �`��
B. Tnteractional evaivations of children and their families
� C. Individual,,�oup,family and couples mental health therapy
D. �fedication evaluations
E. Other services deemed necessary for the prevention of pIacement of children �
4. Service Objectives
� A. Preventin�imminent placement of children '
B. Reunifying children in out-of-home placement with their families.
C. Preventing placement in a more restrictive level of care
D. Developing expedited procedures for permanent placement of children
S. Service Time Frames
a. Service time frames shail be specifically established for each service. �
B. Service time frames shalt be intense,short term,and limited to ane year. �
C. The Viental Health Service must be submitted and approved annually by the State !
Depanmenc
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6. vieasurable Outcomes - measurable sen•ice outcomes and hoW the coant}•proposes co
.,
measure and analyze the outcomes is to be developed and proposed as a part of che county 1,
department's Family Preservation ProQram viental Health Plan. ?�Zeasurable outcomes
shall: ''• '.��
.4. Relate to service obiectives
• B. Be speci$c and measurable
C. $e objective(y detemuned `i:%.;,
D. Relate to cost effectiveness f� '�
E. Prevent out of home placement !•z��'
F. Reunify children with their families
7. Rate Structure/Service Provider-The standards of accountability,professionals and staff � .
expertise are applicable. Counties aze to purchase Mental Health Services from the iocai �
mental heatth center unless the mental heatth center does not offer the needed service or
unless the County was approved to�andfather in certain mental health providers in FY •
1995-96. Mental Health Core Service is not eligible for overhead.
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� ture, IEtECTO O DEPAR'T!vIENT OF SOCIAL SERVICES DATE
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Sisnature,DIRE TO�ME?VT. ALTH CEIvTER DATE
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DRUG/:ILCOHOL TRE:�T1�IEtiT SEIZVICE L1'FO&VL�TION : '
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DruJ9lcohol Treatment Senice Pro�ider\iame(s) ASPEN COWSELING CEUTER �� {'.'�
Drueialcohoi treatment services are approved as a part of the counry(ies)'FPP/Core Services Plan
on an annual basis. Presently, for a drue/alcohot ser�ice to be extended be}�ond one year,this
portion of the ptan must be submitted and agproved annually by the State Department.
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The information listed below is to be submitted in the form of a Dru�/Alcohol Treatment Senices �
Plan and is to be included in the County(ies)'Family Preservation ProgramJ Core Services Plan. `
1. Etigible Population
A. Each child shall meet the criteria of:
I. Colorado's out of home placement criteria
2. Child is at imminent risk of out-of-home placement
3. The county defined child population,and �
4. A manaseable leve]of risk of harm to the child
B. C[vldren may also meet the following criteria: y
- l. Children in out-of-home placement in need of an expedited procedure for
permanent placement
2. Types of Service Provided
A. Drug/alcohol evaluation relating to the faznily siruation �
B. Prevention and education services `;�
, ' C. Individual,group,and family substance abuse ueaunent
' D. AF1 model mentoring
E. Out Patient services
F. Other services deemed necessazy for the prevenrion of placement of children
. 3, Ser�ice Objectives
�. Preventing imminent ptacement of children �
B. Reuni'rying children in out-of-home placement with tfieir families.
C. Preventing placement in a more restrictive level of care
D. DevelopinQ expedited procedures for pennanent piacement of children
4. Service Time Frames
A. Service time frames shall be specificaliy established for each serczce. .
B. Service time frames shal]be iniense,shost tertn,and limited to one yeaz.
C. The DruJ:alcohot Treatment Sen•icz pian musi be submitted and approved
annually by the Scate Deparcment
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�. Measurable Outcomes - measurable service outcomes and how the county proposes to
measure and analyze the outcomes is to be developed and proposed as a pazt of the councv :�.
depaztment's Family Preservation Program/Core Service Plan. vleasurable outcomes �
..�.
shall: ' -
:#. Relate to secvice objectives �
B. Be speci5c and.measurable
C. Be objectively determined
D. Relate to cost effectiveness
E. Prevent out of home placernent
F. Reunify children with their families
6. Staff Qualifications-Staff providing services must be ADAD certified.
� 7. Rate Structure/Service Provider - Whether service is purchased from certified .4DAD
contractors or private providers the standazds of accountability, professionals and staff
expertise are appiicable. (Certified ADAD contractors are those contractors who contract
with the 5tate ADAD Division and receive federa] funding to provide services separate
from Family Issues Cash Fund. The Core Service of DruglAlcohol Treatment is not
e[igible for overhead.
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INFORivI.��TION ON FEES -
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Please check the following which apply: :'.;r
� Fees will not be assessed for Family Preservation Program Services. (STOP. Remainder
of information does not need to be completed.)
Fees will not be assessed for Core Services.
_ Fees will be assessed for the following services: Check those that apply:
_ Home Based Intensive Family Intervention
_ Intensive Family Therapy
Seacual Abuse Treatment
_ Day Treatment
Life Skills
Mental Health Services
_ Drug/Alcohol Services
_ County Designed Service(List Services Below)
�
. �
i _ Transition Service(List Services Betow) .
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Fee assessment formula is the same for all services. State the formula here (attach
additional sheets as needed).
Fee assessment formula varies with service. State formula used for each service.
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F:�i�7II,�'PRESERV'ATIO\PItOGIZ4:�t ',-. �.
OVERgEAD COST �. ';,
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1. PRO�'IDED SERVICE . +. .
A. 2'ocal Salan•iFrineerTrar•e!/Operating Cosu ofLine
Service Vcorkers and their Immediate Supenisors s19,980
B. Formula Percentage Allowed for Overhead Costs 15%
C. Provided Sen�ice Overhead Costs(a X B) 52997
. :?-'�..�,.� '-
3. PLRCH.�SED SERVICE
:�. Purchased Service Do21ar:'�mount S66o0 ;�, �
B. Formula Percentaee Allowed for Overhead Costs Sz :
50-�Q000 =�% 5�0;001-100;000=�.4%
For each S�O,OdO(in totai expendirure}increase the overhead
decreases by.i%. �
C. Allowed Amount for Overhead Costs(.�,X B) S33o
D. Base Overhead Cost Allowed 5500.00 �
E. Purchased Service Overhead Costs(C=D) 5830 !tr
;:
3. TOTaL.OVERHE�DCOSTS(IC-2E1 53827 �� •
DISTRiBLTION OF OVERHEAD COSTS AMONG SERVICES* ;
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: SERVICE provided Senzce Purchased Service ( Total Overhead (
O��erhead Cosu Ocerhead Cosu Coscs ;.
1.Home Bu�Senica(A) � I (' ��
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� ?.Home Based Ser�ices B) $23Z� � I 5232� �
3.Intensive Famil}�Thetap}� I I �830 $830 (
4.Sexual Abuse Therap}� I �
5.Dev Treatment
6.Life Skills $670 $b70
7.Counn•Designed Senice , I
3.Transition Senic� i , I
COLL*?VI\TOT�iLS I g?997 I $830 f $3827 •
"Foanula�o de[ermine overhead cost by senice:
Step 1:total pro�ided serv•ice cost(by service)� 1�%=pro�ided service overhead cost
Step'_':total purcnased senice cost(by service)�°�o listed in?B=Y
5500 di��ded by the number of purchased service=Z,then Y T Z=overhead cost
Step 3:Pro��ded sen•ice overhead cost plus purchased sen-ice o��erhead cost equals rotal _
overhead cost. ' --
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Paga 14
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HOME BASE SERVICES,OP'TION B
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COSI'SLiVIM.�IRY SHEET :�'=
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1. Account Code(either 17XX or 18X3� 1883
2. Totai number of children to be served by provided services 14
3. Total number of children to be served by purchased services r_ .
4. Avera�e number of children(total 2-3)to be served monthly 4 l
5. Total number of families to be served l0
6. average number of families to be served momhly 3
7. Employee FTE number(should be the total staff]isted pa3e l4) 0002
8. Total cost&om page 14 S 15.516
. Overhead cost(Chart on 25,line 2,column l) 5z327
Total provided cost 17 843
9. vlonttily provided cost per chiid $L06•
[this is determined by dividing the total provided cost(8.)by �
(2.)and then dividin�that Lotal by the number of months the
service will be provided.]
10. Total cost from page 20
Overhead cost(Chart on Z5,line 2,column 3)
. Total purchased cost
� 1 i. Monthly purchased cost per child
[this is determined by dividing the total purchased cost(l0.)
by(3.)and then dividing that tocal by the number of months
the service will be pro�ided.]
12. TOTAL COST REQL�ESTED[{8.)+(10.)] 17 843 •
13. Total 30/?0 service cost
14. Total 100%senrice cost requested 517,843 ,
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L\TENSIVE FAVIII..Y THER.�PY .�':
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COST SL1�Ll�L�RY SHEET :�,
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1. Account Code(either 17}t7�or 18k.'Y} 1784 :
_. Total number of children to be served by provided services _
�. Total number of children to be served by purchased services 6 Y-�'
4. Averase number of children(total2-3)to be served monthly Z : . •
�. Total number of families to be sen+ed s
6. Average number oi families to be served monthly Z
7. Employee FTE number(should be the total staff listed page 15)
8. Tota]cost from page 15
_ Overhead cost(Chan on Z5,line 3,column 1)
Total provided cost
9. Monthly provided cost per child
[this is detesmined by dividing the total provided cost(8.)by
(2.)and then dividing that total by the munber of moirths the
service will be provided.]
I0. Total cost from page 21 S6600
Overhead cost(Chart on 2�,line 3,column 2) 5830
. Total purchased cost �7430
� 1I. Monthly purchased cost per chiid slo'�
[this is determined by dividin�the total purchased cost(10.)
by(3.)and then di��ding that total by the number of months
the service wili be provided.]
12. TOT:#L COST REQIIEST'ED((8.)+(10.)) $7430
13. Total 80/30 service cost S743o
14. Tocal 100%service cost requested
Page 16
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LIF'E SKILLS �`
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COST STJM_1�1.1RY SHEET ', +, ,
l. .account Code(either 17�3C or 18X� 2885
2. Totai number of children to be served by pro�ided services 6
r ',
3. Total number of children to be served by purchased services .
4. Average number of children(total2=3)to be served monthfy 3
5. Tocal number of families to be served a
6. Average number of famiIies co be served monttily 2
7. Employee FTE number(shoufd be the total staff listed pa�e 16) 0006 �
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!
8. Total cost from paee 16 54464
' Overhead cost(Chart on 25,line 4,column 1) 5670 �
Total provided cost 5134
9. Vfont}ily provided cost per child 71 ��
[this is deteimined by dividing the total provided cost(8.)by .
(2.)and then dividing that total by the number of months the
- service will be provided.]
10. Total cost from page 22
Overhead cost(Chart on 35,line 4,coiumn Z)
Total purchased cost
11. Monthly purchased cost per child
[this is detemvned by dividinQ the total purchased cost(10.)
by(3.)and then dividino that total by the number of months
the service will be provided.]
12. TOT�L C�ST REQUESTED j(8.)+(10.)] $5134
13. Total 30/?0 service cost
1�. Total 100%service cost requested s5134 �
I _-
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Page 17 �
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FL\AL BL"DGET PAGE --
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F.��,Y PRESERV aTIOh PROGR�vI • " �':
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.4ccount Senice tiame Other Other Total Total TOTAL .,
Code DSS I Source Funds F�'� FPP J`'..?,.
Funds � FundS 80/20 100% FLi�iDS
i :.:'.'t'..�'_
83 HOME BASED — B ( $17,843 $17,843
84 FAMILY THERAPY I 57430 � �$7430 �
85 LIFE SKILLS $5134 55134
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TOT.�I.S !
57430 $22,977 $30,407
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COST S[,�IVL�RY SHEET �-. 1.
i. Account Code(either 17?�C or 1 S7L`C) 1887 .�,�': •
i .
2. Total number of children to be served by provided services
3. Total number of chiidren ta be served by purchased services 4
. ';;..7...:
�. Averase number of chiidren{total2�-�)to be served monthly 2
�. Total number of faznilies to be served 6 •
6. Avecage number of families to be served monthiy 3 ;:
7. Emptoyee FTE number(should be the tota]staff Gsced page 18)
8. Total cost from page 18 ±
Overhead cost{Chart on 25,line 6,column l)
_ Totai provided cost � .
9. Monthly provided cost per child
(this is determined by dividin�the total provided cost(8.)by
(2.)and then dividing ihat totai by the number of months the
service wiU be pro�ided.] ���
10. Total cost from pa�e 24 �3900
Overhead cost(Chart on 25,line 6,column 2) 5695 � .
Total purchased cost 54595 :
, 1 I. Monthly purchased cost per child S96
[this is determined by dividin�the total purchased cost(I0.)
by(3.)and then dividine that total by the number of months
the service will be provided.]
12. TOTaL C�ST REQUEST'ED[(8.}+(10.)] 54595
13. Total S0;?0 service cost
14. Total]00°%senlce cost requested 84595
� -_
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Page 23
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PART II t�' . ;-�`;
• .`,,
F.��III.�"PRESER4:�TIOr PROGR�.:vI
O��RHE:�D COST ;'' `•
ti.
l. PROVIDED SERVICE ' �,. f .
.�. Tocal SalarviFringe%Travel/Operatin�Cosu of Line �
Service t�4orkers and their Immediate Supervisors ��`
B. Formula Percentase.�llowed for Overhead Costs 15%
C. Provided Service Overhead Cosu(A X B} f.`�
����:Y'. '.
3 PLRCH.aSED SERVICE
3. Purchased Service Dollar�mount 53900 t�� .
i
B. Formula Percenta�e allowed for Overhead Costs 5� ,
$0->Q�00 =�% 5�0,001-100,000=4.9% "
For each 550,000(in total expendicure)increase the overhead
decreases bv.1°'o. .
C. ?1lowed:lmount for Overhead Costs(.A X B) s195 •
D. Base Overhead Cost�ilowed 3500.00
E. Purchased Service Overhead Cosu(C=D) 5695 +%f.
3. TOTf1i.OVERHEaD COSTS(1C=3E) 5695 �('
L
DISTRIBL'CION OF OVERHEAD COSTS r1MOIvG SER4zCE5"` �
7
SEAVICE I provided Service I Purchased Service Tota!Overhead `
Overhead Costs Overhead Cosu Costs �
t;,is
�.HOIRC B35Cd$CIti7CCS{'e�) I � �'.
�.Hame Based Services(B) ! 1 �
_ � j
3.Intensive Familc I'herapy •
f
1.Se.xual Abuse i'hetapy ¢695 5695 �
i.Day Trpunent � '
6.Life Skills � I
7.Counn•Desi,ced Service I
S.Transition Senice I '
COLUbi;i TOT.4LS , ` $695 5695
'Formula co detecmine overhead cosc by service:
Step 1:totzl provided service cost(by secvice)x 1�%=provided service overhead cost
Step 3:total purchased ser��ice cost(by service)x%lissed in 2B=Y
550�divided by the number of purchased service=Z,then Y+Z=overhead cost ,
5tep 3:Protizded service overhead cost pius purchased service overhead cost equats total .
overhead cost. --
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F-�vIILY PRESERt%;#TIO�V PROGTLa�i �'
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Acrnunt Senice Vame Other I Other Totai Total TOT�L •`
Code I DSS Source Funds F�� �'�
Funds � Funds 30120 t���0 Fli�1D5 •
1887 SEXVAL ABIISE TREATTtEN� � � ( 54595 !54595 ' ';r.`.'
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