The Core Team Is Expected To

Part 2: Collaborative Application Form

2010 Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Learning Collaborative Application Packet

Site Contact Information

Enter the Agency/ Site Name:

Information for completing site contact information

v Teams are comprised of three to five members.

v A team needs to include at least ONE senior leader, ONE clinical supervisor, and ONE clinician. It is highly recommended that each team include at least TWO clinicians.

v For each team member identified below, you will be asked to identify their role—senior leader, clinical supervisor, clinician, or other. (If you check “other” you will be asked to specify the team member’s role; for example, “community partner.”) We recognize that many individuals may have dual roles in their agency (e.g., senior leader and supervisor). Each team member can choose a primary and a secondary role (if applicable). The identified primary role will be used to assign team members to appropriate tracks at learning sessions and collaborative call groupings. It is still important to capture each member’s secondary role to assist the faculty in planning the activities for the learning sessions.

v There will be an opportunity to identify up to eight individuals for your team. Team Members 6, 7, and 8 will be put on an optional list and will be accepted to the collaborative if possible, based on demand and resource considerations.

v Each team needs to identify a data manager to coordinate certain tasks for the metrics and collaborative evaluation. The data manager can be a team member or someone else at the agency.

Identify one name from Team Members 1-5 that will serve as the Contact Person. This individual will be your site’s main point person and will receive all communications and materials regarding the TF-CBT Learning Collaborative application and follow-up process.
Contact Person: ______

Team Member #1

Name:
Title:
Telephone Number:
Email Address:
Fax Number:
Mailing Address:
Primary Role: (Select one)
Senior Leader Clinical Supervisor Clinician
Other, specify role:
Secondary Role, if applicable: (Select one)
Senior Leader Clinical Supervisor Clinician
Other, specify role:

Team Member #2

Team Member #3

Team Member #4:

Team Member #5

Team Member #6 (OPTIONAL)

Team Member #7 (OPTIONAL)

Team Member #8 (OPTIONAL)

Data Manager

If the data manager is not a team member (listed above), please include his/her contact information; otherwise, you can just provide the data manager’s name.

Name:
Title:
Telephone Number:
Email Address:
Fax Number:
Mailing Address:

Description of Agency, Team, Implementation Plans, and Experience

Instructions for completing this section

v Answer all of the questions directly on this form.

v Please be succinct as the goal is to get a general sense of your organization, including implementation plans and experience in areas relevant to this LC.

v It is recommended to have all members of your proposed team involved in completing this application.

1. Briefly describe your agency/site including: type of organization, size, client population, key referral sources, types of trauma served, and whether families come to the agency specifically to receive trauma-focused services. Please include a description of how clinical services are funded (e.g., grants, private insurance, Medicaid).

2. TF-CBT was designed to assist children, adolescents, and their families who have been exposed to traumatic events. TF-CBT has been found to be particularly effective in addressing symptoms of post-traumatic stress disorder (PTSD). This treatment model may not be ideally suited for children whose primary presentation is for very severe behavioral disruptions. TF-CBT is typically utilized in outpatient settings, in residential treatment facilities, in schools, or in homes/ foster care homes where there is a non-offending caregiver or other adult available to participate in treatment.

What is the target population(s) with which your team plans to implement TF-CBT during this LC? Please describe the setting(s) in which the practice will be implemented, age range of the youth who will receive TF-CBT, and any other pertinent characteristics of the target population (e.g., Latino families, multiply-traumatized youth, preschoolers).

3. Will your agency be partnering with staff from another location to implement TF-CBT (e.g., a school, group home)? No Yes → If yes, please respond to the questions below.

· Have you implemented TF-CBT or other manual guided treatments at this location before? No Yes → If yes, please describe the treatment(s) implemented and any challenges encountered.

· How do you plan to orient staff at your partnering agency to the TF-CBT model and LC expectations (e.g., importance of caregiver participation, requisite clinical assessments)?

4. As noted in Part I of this Application Packet, supervisors participating in the LC are expected to begin providing TF-CBT by late June/early July (before LS1), and participating clinicians are expected to begin providing TF-CBT by October. How does the agency plan to identify potential TF-CBT clients? How will children and families be screened to ensure that they are appropriate for this treatment? When will the process of identifying and screening clients for TF-CBT begin?

5. For each of the three categories below, please answer the following questions related to level of experience in implementing TF-CBT and other evidence-based practices (EBPs):

a) The agency: Is TF-CBT currently being utilized in other programs in the agency? Describe any prior experience your agency has had using other EBPs.

b) Team supervisor: Describe the supervisor’s experience with TF-CBT and other EBPs. What is the supervisor’s overall theoretical and clinical orientation? What percentage of the supervisor’s time is spent on clinical supervision vs. administrative supervision?

c) Team clinicians: Describe each clinician’s experience with TF-CBT and other EBPs.

6. What are the key challenges your organization faces in implementing and sustaining the use of TF-CBT at your agency? Areas to consider include:

a) level of support from staff at all levels of the agency, particularly senior leadership;

b) capacity to identify and screen referrals;

c) experience using standardized assessments to evaluate client progress;

d) agency commitment to providing ongoing supervision in evidence-based practices; and

e) capacity to continue to monitor progress toward adoption of TF-CBT, including treatment fidelity.

Team Expectations

Instructions for completing team expectations

v For each expectation, choose the response that best describes your team’s ability to meet that expectation. Please comment on challenges to your team’s ability to meet these expectations and propose potential solutions.

v Completing this portion of the application as a team is recommended (either in a face-to-face format or through synthesizing feedback from each team member).

v “Challenges and proposed solutions” must be addressed if No/Not sure is selected for a particular expectation. However, it is NOT necessary to comment on an expectation if your team does not believe there are significant barriers to meeting it.

All team members will:

v Participate in pre-work calls and activities, including completion of an organizational assessment that helps teams identify systemic challenges and set site-specific goals.

Yes No/Not sure