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SMALL GROUP HOME BASED SERVICES
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SOLICITATION DHHS91266
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 SCORE SHEET
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Applicant:
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Evaluator:Date:
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Award Summary:
The award status in the table below is based on the results of the Application Evaluation (below the award summary table).
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Service Codes Selected (from Form #4)Is this service selected on Form #4?Is this service being awarded?
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Behavioral and Emotional Needs Services (DBX).
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Award of this service also includes:
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Absence Residential Behavioral Small Group Home (ABX) and
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and Contracted Transportation Payment (CTP).
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Disability Needs Services (DDX)
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Award of this service also includes:
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Absence Residential Disability Small Group Home (ADX) and
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Contracted Transportation Payment (CTP).
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Application Evaluation Pass/FailEVALUATOR NOTES
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Evaluator Instructions: Mark in the column at the left whether the Applicant submitted each item, completed as instructed on the form.Evaluator may use this space to indicate additional information requested, etc.
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1Form #1 - Data Sheet
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2Form #2 - IRS Form W-9 completed in the legal name of the business entity or individual applying for this solicitation that is signed and dated within one year of submission date.
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3Form #3 - Conflict of Interest Disclosure Statement
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4Form #4 - Service Application
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5Form #5 - Proof of Qualifications. Indicate whether the Applicant submitted the required documentation.
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Form #5, Section A: Mandatory requirements for ALL applicants.
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1. CONTRACT: DHHS 91073 Clinical Evaluation and Treatment, Wrap Non-Clinical Support Services, and Forensic Evaluations (CETW). Did the Applicant provide the CETW contract # for either Option #1 or Option #2 below? Does the contract include an award of Psychotherapy Services and Psychosocial Rehabilitative Services?
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Option #1: Applicant has a current (fully signed) CETW contract that includes Psychotherapy Services and Psychosocial Rehabilitative Services.
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Option #2: Applicant subcontracts with a provider who has a current (fully signed) CETW contract that includes Psychotherapy Services and Psychosocial Rehabilitative Services.
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2. LICENSE: Residential Support Home. Applicant must submit proof of having a current Residential Support Home License issued by the Department of Health and Human Service Office of Licensing and Background Checks (“DHHS/OL”).
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3. EXPERIENCE: Manager or Clinician. Applicant must submit proof in the form of a resume or CV that it employs a manager or clinician with at least five years’ experience providing child welfare services to children in care due to abuse or neglect.
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Form # 5, Section B: Requirement for providers applying for Disability Needs Services (service code DDX)
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CONTRACT: DHHS 91172 Intellectual Disabilities, Related Conditions and/or Acquired Brain Injury (ID.RC/ABI)
In order to qualify to provide DDX services, Applicants must have a current (fully signed) ID.RC/ABI contract that includes Residential Habilitation Supports services.

1) Did Applicant provide their ID.RC / ABI contract#? 2) Does the Applicant's contract include Residential Habilitation Supports services?
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6Form #6 - Technical Criteria.
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1. Applicant must submit documentation to support how the Applicant’s program meets the SOW requirements for its treatment model, type and structure of treatment and interventions, including behavioral interventions. Submittion must include program completion and transition planning. (See Scope of Work Section 4.4 Direct Services and Coordination.). Applicant must type a list on the form indicating the documents they submitted.
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2. Applicant must indicate on the form which population(s) it will be serving. If serving both populations, Applicant must provide a description of how they will adhere to the mixing population portions of the SOW, Section 4.3 Placement Requirements.
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3. Applicant must submit a sample treatment plan. Treatment plan must incorporate the following as defined in the SOW, Section 4.1 Program Model: identifiable goals, incorporate the family, family visitation, transition planning.
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4. Applicant must submit their training and onboarding process for families involved in placement of clients per the SOW, Section 3.3 Staffing Requirements for Clinical Oversight.
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5. Applicant must submit a copy of their program manual. The program manual must identify how the Applicant will maintain fidelity to its identified program model(s)/treatment model(s), including but not limited to staff training, certifications, and outcome measures, including specific examples per the SOW Section 4.1 Program Model.
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RESULT:
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