ATTACHMENTD
Proposed Services Form
This form outlines what you plan to accomplish with the Children’s Advocacy Centers Child Centered Services VOCA Initiative grant and should align with the project narrative completed in Attachment D.
Please refer to the Service Standards for information about the kinds of activities that are eligible (Appendix A). Eligible services include:
ATTACHMENTD
- Child Advocacy Center Services
- Forensic Interviews
- Multidisciplinary Team Coordination
- Therapy
- Medical Social Work
ATTACHMENTD
ATTACHMENTD
A sample form is included for reference.
The blank form can be found on the last page.
Column 1 – Staff Name and Position
List the name and job title of the person providing the service.
Column 2 – Type of Service
List which Service Standard applies to the activity you want to do.
Column 3 – Activity and Geographic Area to Be Served
List the activity you are providing, and where you will be providing it (geographic area). If services will be provided in more than one county and/or geographic area, please indicate this (each area should be a separate line).
Column 4 – Description of Service and Population Served
Provide a brief description of the activity and include the specific community to receive the service.
Column 5 – Approximate Number of People to Receive Service
Provide an approximate number of how many people will receive the service.
Therapy services have supervision and case consultation requirements. Please include the name(s) and title(s) of the individual(s) providing supervision and case consultationat the bottom of the form.
Attachment D
SAMPLE Proposed Services Form
Service Period: January 1, 2017 thru June 30, 2018
Staff Name and Position / Type of Service / Geographic Area to be Served / Description of Service & Population to be Served / Approx. # of People to Receive ServiceNicole Smith
Therapist / Therapy / Fake County / Provide Individual Therapy to female adolescent victims of sexual assault / 15
Ron Foster
Therapist / Family Therapy / Fake County / Provide Family Therapy for families of male victims of sexual abuse / 6
Nicole Smith
Ron Foster
Therapists / Group Therapy / Fake County / Provide two 8-week Therapy Groups for male adolescent survivors of child sexual abuse / 6
Jill Lyon
Nurse Practitioner / Medical Social Work / Fake County / Provide Medical Social Work for child victims of sexual abuse and assault / 75
Hope Springs,
MDT Coordinator / MDT Coordination / Fake County / Share agenda, meeting minutes, and issues to be addressed with monthly MDT meetings participants. Reach out to service providers as needed regarding participation / 75
Hope Springs,
MDT Coordinator / MDT Coordination / Fake County / Manage child/youth cases by coordinating appointments, follow up, and service connections and helping each client access community and system based resources and stay informed / 75
Hope Springs,
MDT Coordinator / Forensic Interview / Fake County / Provide forensic interviews to child and youth victims / 75
Attachment D
Proposed Services Form
Service Period: January 1, 2017 thru June 30, 2018
Staff Name and Position / Type of Service / Geographic Area to be Served / Description of Service & Population to be Served / Approx. # of People to Receive ServiceFor Therapy and Forensic Interview Services: Supervision and case consultation are a grant requirement. Please list the name(s) and title of the individuals providing this below.
Therapy:
Regular supervision, consultation and/or review of cases provided by:
Forensic Interviews:
Regular supervision, consultation and/or review of cases provided by: