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Page 12 of 53 <br />FORM 4.02 PRICE SHEET <br />REQUEST FOR PROPOSAL #2024-163 MENTAL HEALTH SERVICES <br />Supplier Name: <br />The supplier must provide a firm, fixed, not-to-exceed subtotal for each deliverable, including all services <br />listed in Section 2. The proposer must consider all costs associated with providing the services listed in <br />this RFP, such as labor, overhead, administration, travel, etc. <br />Clearly identify any services mentioned in your response that are not included in your proposed fee, such as <br />services that would be an additional expense. <br />Requested Services and Pricing <br />Firm Fixed, Not To Exceed, Amount to provide both deliverables below. $ <br />Task Breakdown Price per <br />Session <br />Estimated <br />Sessions Cost <br />Deliverable: Individual One (1) - hour appointments $ 65 $ <br />Deliverable: Individual One (1) - hour follow-up <br />appointments. Billed per appointment. $ 65 $ <br />Additional Services <br />Task Breakdown Price per hour <br />$ <br />$ <br />$ <br />••••• •••••••• •••• ••• •• ••• •• •• ••• •• ••