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Master Blanket Purchase Order ADCS16-119235

Header Information
Purchase Order Number: ADCS16-119235 Release Number: 0 Short Description: Counseling & Consultation Services
Status: 3PS - Sent Purchaser: Delilah Gonzalez Receipt Method: Quantity
Fiscal Year: 2016 PO Type: Blanket Minor Status:
Organization: Arizona Department of Child Safety
Department: OP - Office of Procurement Location: OP - Contracts Type Code:
Alternate ID: Entered Date: 12/24/2015 09:22:07 AM Control Code:
Days ARO: 30 Retainage %: 0.00% Discount %: 0.00%
Print Dest Detail: If Different
Catalog ID: Release Type: Direct Release Pcard Enabled: No
Contact Instructions: Delilah Gonzalez 602-255-2887 at Delilah.Gonzalez@azdcs.gov Tax Rate: Actual Cost: $1,280.00
Master Blanket/Contract End Date (Maximum): 12/31/2020 11:59:59 PM
Project No.:
Special Purchase Types:
PIJ NUMBER:
Commodity Reference Id:
PO External Doc Type: None
Agency Attachments: 01 Pre-solicitation Documents.zip 02 Solicitation Documents.zip Counseling_Consultation Services RFP rev 10-21-15.pdf Exhibit 1 Limited English Proficiency Policy~28.pdf Exhibit A J.K. Principles~3.pdf Exhibit B Progress Report CSO-1139A~1.doc Exhibit C DCS Unit Consult Log and Verification of Client Services-Clinical-Cnslg~1.doc Exhibit D DCS Counseling Consultation Services Invoice~1.xlsx Exhibit E ADJC Verification of Juvenile Services-Clinical-Counseling~1.doc Exhibit F ADJC Service Providers Unusual-Significant Incident Report Protocol rev 10-23-15.pdf Exhibit F ADJC Service Providers Unusual-Significant Incident Report Protocol rev 10-23-15~1.pdf Exhibit G DCS Significant Incident Report CSO-1151A~1.doc Exhibit H Clinical Family Assessment rev 10-23-15~1.doc Exhibit I Quarterly Data Report~1.xlsx Exhibit M ADJC Program Evaluation~1.pdf Signed HITECH Business Associate Agreement Integrity Counseling_Award Letter Signed Offer and Acceptance Teresa Kolodny - Professional License Renewals.pdf Teresa Kolodny - Amendment 1~1.docx Contract Amendment 2~25.zip Contract Amendment 3~63.zip
Vendor Attachments: ADCS Independent Contractor Agreement.pdf ADCS Sole Proprietor Waiver.pdf BAFO.DCS Qualified Contractor Application rev 10-21-15.01.doc BAFO.DCSAttachment 02 List of References.docx BAFO.DCSAttachment 03 Licensure-Certification Attestation_rev 10-21-15.docx BAFO.DCS Confidential Designation and Trade Secret~1.pdf BAFO.Lic. LPC.pdf
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 000005098 - INTEGRITY COUNSELING PLLC
Teresa Kolodny
11092 E Placita Cumbia
Tucson, AZ 85730
US
Email: INTEGRITYCOUNSELING.TK@GMAIL.COM
Phone: (520)370-9032
FAX: (520)370-9032
Alt. Reference: Z0002
Payment Terms: Net 30 Shipping Method: Best Way
Shipping Terms: TBD Freight Terms: Freight Prepaid
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to INTEGRITYCOUNSELING.TK@GMAIL.COM at 12/25/2015 06:51:04 AM 12/26/2016 09:55:37 AM
Change Order 1 Emailed to INTEGRITYCOUNSELING.TK@GMAIL.COM at 12/27/2016 07:25:06 AM 12/27/2016 09:01:57 AM
Change Order 2 Emailed to INTEGRITYCOUNSELING.TK@GMAIL.COM at 12/12/2017 03:47:46 PM
Change Order 3 Emailed to INTEGRITYCOUNSELING.TK@GMAIL.COM at 10/03/2018 08:11:59 AM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
000005098
PZ000005098 INTEGRITY COUNSELING PLLC Email Active
Master Blanket/Contract Controls
Master Blanket/Contract Begin Date: 01/01/2016 Master Blanket/Contract End Date: 12/31/2019
Cooperative Purchasing Allowed: Yes
Organization Department Dollar Limit Dollars Spent to Date Minimum Order Amount
ADCS - Arizona Department of Child Safety AGY - Agency Umbrella Master Control $0.00 $0.00 $0.00
ADES - Arizona Department of Economic Security AGY - Agency Umbrella Master Control $0.00 $0.00 $0.00
ADJC - Arizona Department of Juvenile Corrections AGY - Agency Umbrella Master Control $0.00 $0.00 $0.00
Item Information   
1-5 of 12
1 2  3 
Print Sequence # 1.0, Item # 1:   One (1) Hour Consultation - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 1 Quote # / Quote Item #:  000035615-R1 / 1
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $90.00 HR - Hour 0.00 $0.00 $0.00 $90.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 2.0, Item # 2:   One (1) Hour Consultation - Rural 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 2 Quote # / Quote Item #:  000035615-R1 / 2
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $100.00 HR - Hour 0.00 $0.00 $0.00 $100.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 3.0, Item # 3:   One (1) Hour Unit Consultation - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 3 Quote # / Quote Item #:  000035615-R1 / 3
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $90.00 HR - Hour 0.00 $0.00 $0.00 $90.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 4.0, Item # 4:   One (1) Hour Unit Consultation - Rural 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 4 Quote # / Quote Item #:  000035615-R1 / 4
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $100.00 EA - Each 0.00 $0.00 $0.00 $100.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
Print Sequence # 5.0, Item # 5:   One (1) Therapy Hour of Individual and/or Family Counseling: Office Setting - Urban 3PS - Sent
NIGP Code: 952-59
   Counseling/Consultation Program: HP04-00
Bid # / Bid Item #:  ADCS16-00005689 / 5 Quote # / Quote Item #:  000035615-R1 / 5
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $90.00 HR - Hour 0.00 $0.00 $0.00 $90.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
1-5 of 12
1 2  3 
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