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Master Blanket Purchase Order ADCS16-119239

Header Information
Purchase Order Number: ADCS16-119239 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: OP2 - Purchasing Type Code:
Alternate ID: Entered Date: 12/24/2015 09:22:07 AM Control Code:
Days ARO: 0 Retainage %: 0.00% Discount %: 0.00%
Print Dest Detail: If Different
Catalog ID: Release Type: Direct Release Pcard Enabled: No
Contact Instructions: Delilah Gonzalez at 602-255-2887 or Delilah.Gonzalez@azdcs.gov Tax Rate: Actual Cost: $1,680.00
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:
Agency Attachments: 01 Pre-solicitation Documents.zip 02 Solicitation Documents.zip Determination to allow Multi-Agency Contracts for Psychiatric Psychological Counseling Services~1.pdf Counseling_Consultation Services RFP rev 10-21-15.pdf Exhibit 1 Limited English Proficiency Policy~32.pdf Exhibit A J.K. Principles~7.pdf Exhibit B Progress Report CSO-1139A~5.doc Exhibit C DCS Unit Consult Log and Verification of Client Services-Clinical-Cnslg~5.doc Exhibit D DCS Counseling Consultation Services Invoice~6.xlsx Exhibit E ADJC Verification of Juvenile Services-Clinical-Counseling~6.doc Exhibit F ADJC Service Providers Unusual-Significant Incident Report Protocol rev 10-23-15~5.pdf Exhibit G DCS Significant Incident Report CSO-1151A~5.doc Exhibit H Clinical Family Assessment rev 10-23-15~5.doc Exhibit I Quarterly Data Report~5.xlsx Signed HITECH HIPPA Form Signed Offer and Acceptance Trilogy Psych Svcs_ AwardLetter DC16-119239 TRILOGY COI 5.20.2016.pdf Trilogy Integrated Psych Services COI Exp 2262017.pdf Contract Amendment 1 Listing of Employees-Subcontractors Korsten Celice- License ContractorCOI_2-26-17 Contract Amendment 2 Contract Amendment 3~79.zip
Vendor Attachments: Offer & Acceptance Attachment 01 Attachment 02 Attachment 03 Attachment 04 Sole Proprietor Waiver Independent Contractor Agreement Designation of Confidential, Trade Secret & Proprietary Information HITECH Business Associate Agreement Statement Declaring All Anticipated Offshore Services Copy of DHS License
Agency Attachment Forms:
Vendor Attachment Forms:
Primary Vendor Information & PO Terms
Vendor: 000025256 - Trilogy Psychological Services, LLC
Nicole Huggins
4135 South Power Road
Suite 118
Mesa, AZ 85212
US
Email: trilogypsychological@gmail.com
Phone: (480)813-3990
FAX: (480)813-3933
Website: http://www.trilogypsychological.com
Alt. Reference: Z0001
Payment Terms: Shipping Method:
Shipping Terms: Freight Terms:
PO Acknowledgements:
Document Notifications Acknowledged Date/Time
Purchase Order Emailed to trilogypsychological@gmail.com at 12/29/2015 12:29:55 PM 02/12/2016 01:17:29 PM
Change Order 1 Emailed to trilogypsychological@gmail.com at 09/01/2016 01:08:08 PM
Change Order 2 Emailed to trilogypsychological@gmail.com at 09/01/2016 01:10:24 PM 09/01/2016 01:14:38 PM
Change Order 3 Emailed to trilogypsychological@gmail.com at 12/23/2016 03:48:38 PM 12/27/2016 10:34:34 AM
Change Order 4 Emailed to trilogypsychological@gmail.com at 12/25/2017 01:06:56 PM 01/02/2018 08:06:08 AM
Change Order 5 Emailed to trilogypsychological@gmail.com at 10/12/2018 01:06:54 PM 10/18/2018 01:23:54 PM
Master Blanket/Contract Vendor Distributor List
Vendor ID Alternative ID Vendor Name Preferred Delivery Method Vendor Distributor Status
000025256
PZ000025256 Trilogy Psychological Services, LLC 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 #:  000035796-R1 / 1
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $125.00 HR - Hour 0.00 $0.00 $0.00 $125.00
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 #:  000035796-R1 / 2
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $125.00 HR - Hour 0.00 $0.00 $0.00 $125.00
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 #:  000035796-R1 / 3
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $125.00 HR - Hour 0.00 $0.00 $0.00 $125.00
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 #:  000035796-R1 / 4
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $125.00 EA - Each 0.00 $0.00 $0.00 $125.00
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 #:  000035796-R1 / 5
Receipt Method Qty Unit Cost UOM Discount % Total Discount Amt. Tax Rate Tax Amount Total Cost
Quantity 1.0 $125.00 HR - Hour 0.00 $0.00 $0.00 $125.00
Manufacturer: Brand: Model:
Make: Packaging:
Property Number:
 
1-5 of 12
1 2  3 
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