TEACHING-FAMILY ASSOCIATION
INITIAL APPLICATION FOR CERTIFICATION
[Instructions on how to complete this application as well as a glossary of terms to help define various terms are posted on the TFA website. Please print a copy of these resources to assist you with this application.]
COVER SHEET
NAME OF AGENCY:AGENCY DIRECTOR(S):
SPONSOR AGENCY:
POPULATIONS SERVED:
PERSON(S) RESPONSIBLE FOR COMPLETING THIS APPLICATION:
NAME:
PHONE:
The member agency is applying for certification as a: (check one)
Certified Member Agency (an agency that provides administrative
services and two of the three Teaching-Family Model Integrated
Systems and contracts with a sponsor agency for the third)
Certified Sponsor Member Agency (an agency that provides all
integrated systems)
Date of Application / Agency Director's Signature
TEACHING-FAMILY ASSOCIATION
INITIAL APPLICATION CHECKLIST
1. *INITIAL APPLICATION COVER SHEET
2. *INITIAL APPLICATION CHECKLIST
3. *AGENCY RESPONSIBILITIES ASSURANCES AGREEMENT
4. †SPONSOR AGENCY’S READINESS ASSESSMENT
5. *AGENCY DIRECTOR’S NARRATIVE
6. *AGENCY DESCRIPTION
7. †AGENCY ORGANIZATIONAL CHART
8. *PROGRAM ROSTER
9. *OTHER PROGRAMS ROSTER
10. *AGENCY STAFF ROSTER
11. **AGENCY STAFF RESUMES
12. **PRE-SERVICE TRAINING REPORT
13. **PRE-SERVICE TRAINING TOPICS/OUTLINE
14. **IN-SERVICE TRAINING REPORT
15. **CONSULTATION SERVICES REPORT
16. *EVALUATION POLICIES AND PROCEDURES
17. *LIST OF EVALUATED PRACTITIONERS
18. *INCLUDE OUTCOMES INFORMATION AND DATA REPORTS
19. †SAMPLE OF PRACTITIONER EVALUATIONS FOR CERTIFICATION
20. †*AGENCY CONSUMER SATISFACTION REPORT
21. †*PRACTITIONER CONSUMER SATISFACTION REPORT
22. †*AGENCY STAFF EVALUATION OF SPONSOR AGENCY SERVICES REPORT
23. †POLICIES AND PROCEDURES REGARDING ETHICAL PRACTICES
24. MAKE SUFFICIENT COPIES AND PLACE IN 3-RING BINDER(S) WITH TAB DIVIDERS
25. MAIL/SUBMIT COPIES DIRECTLY TO REVIEW TEAM MEMBERS AND TFA OFFICE
*(*) Standardized electronic forms are provided within this document for those items marked with asterisk(s). Using these forms facilitates easy entry, organization, and on-going management of application materials. However, agencies have the option to provideadditional forms or documentation for those items marked with two asterisks
† These documents are not included within these application materials and must be produced separately.
TEACHING-FAMILY ASSOCIATION
AGENCY RESPONSIBILITIES ASSURANCES AGREEMENT
Member Agencies of the Teaching-Family Association agree to participate in the goals and objectives of the organization. Directors of Member Agencies are responsible for the participation of their agency. The submission of the Initial Application for Agency Certification materials and the Agency Director's signature on this agreement serve as an assurance that the agency has fulfilled the following obligations.
1.The agency has provided each new employee a copy of Standards of Ethical Conduct of the Teaching-Family Association and has provided accompanying formal instruction on the implementation of those Standards. This information has been provided to all employees as a function of the agency's membership in the Association rather than as a function of the employee's membership in the Association.
2.The agency has abided by all Standards of Ethical Conduct of the Association.
3.The agency has participated in the work of the Association by providing a representative to the certification and ethics committee and volunteers for other standing committees.
4.The agency has provided immediate notification to the Board of Directors and the appropriate standing committee chairpersons of new sponsor agency affiliations and disaffiliations.
5.The agency has paid annual agency dues in accordance with Association policy.
6.The agency has maintained the Association documentation and materials assigned to the agency and ensured that appropriate administrative personnel at the agency are thoroughly familiar with the materials and their evolution.
As the Agency Director for / ,(Agency Name)
I commit my agency to the preceding assurances.
Date / (Print Agency Director’s Name)
This Area to be Filled in by TFA Office
Dues Payment Received from Agency
YES Date ______No
Signature of Agency Director
Exec. Director Initials ______
TEACHING-FAMILY ASSOCIATION
AGENCY DIRECTOR’S NARRATIVE
TEACHING-FAMILY ASSOCIATION
AGENCY DESCRIPTION
TEACHING-FAMILY ASSOCIATION
PROGRAM/SERVICES ROSTER
List any agency programs which incorporate all the Teaching-Family Model Integrated Services. Therapeutic Foster Programs and other broad-based programs can be listed as a collective program. However, list each group home, school, or other type of treatment center separately. Indicate the name, the location, the type of program (i.e., group home, school, home-based, etc.), the population served (i.e., youths at risk, juvenile offenders, autistic children, etc.), the program’s capacity, either the names of practitioners or the total number of practitioners. Under Staff, indicate the names of and/or number of staff that provides support to the practitioners in those programs.
PROGRAM NAME/LOCALES / TYPE OF PROGRAM / POPULATION SERVED / CAPACITY / PRACTITIONERS (#) / STAFF (#)(Continue to next page if more space is needed. If not, proceed to “Other Program Roster” form.)
1
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
PROGRAM/SERVICES ROSTER, Cont.
List any agency programs which incorporate all the Teaching-Family Model Integrated Services. Therapeutic Foster Programs and other broad-based programs can be listed as a collective program. However, list each group home, school, or other type of treatment center separately. Indicate the name, the location, the type of program (i.e., group home, school, home-based, etc.), the population served (i.e., youths at risk, juvenile offenders, autistic children, etc.), the program’s capacity, either the names of practitioners or the total number of practitioners. Under Staff, indicate the names of and/or number of staff that provides support to the practitioners in those programs.
PROGRAM NAME/LOCALES / TYPE OF PROGRAM / POPULATION SERVED / CAPACITY / PRACTITIONERS (#) / STAFF (#)(Continue to next page if more space is needed. If not, proceed to “Other Program Roster” form.)
1-B
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
PROGRAM/SERVICES ROSTER, Cont.
List any agency programs which incorporate all the Teaching-Family Model Integrated Services. Therapeutic Foster Programs and other broad-based programs can be listed as a collective program. However, list each group home, school, or other type of treatment center separately. Indicate the name, the location, the type of program (i.e., group home, school, home-based, etc.), the population served (i.e., youths at risk, juvenile offenders, autistic children, etc.), the program’s capacity, either the names of practitioners or the total number of practitioners. Under Staff, indicate the names of and/or number of staff that provides support to the practitioners in those programs.
PROGRAM NAME/LOCALES / TYPE OF PR / POPULATION SERVED / CAPACITY / PRACTITIONERS (#) / STAFF (#)(Continue to next page if more space is needed. If not, proceed to “Other Program Roster” form.)
1-C
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
PROGRAM/SERVICES ROSTER, Cont.
List any agency programs which incorporate all the Teaching-Family Model Integrated Services. Therapeutic Foster Programs and other broad-based programs can be listed as a collective program. However, list each group home, school, or other type of treatment center separately. Indicate the name, the location, the type of program (i.e., group home, school, home-based, etc.), the population served (i.e., youths at risk, juvenile offenders, autistic children, etc.), the program’s capacity, either the names of practitioners or the total number of practitioners. Under Staff, indicate what other staff have involvement in the program (e.g., awake night staff, therapist, school liaison, etc.)
PROGRAM NAME/LOCALES / TYPE OF PROGRAM / POPULATION SERVED / CAPACITY / PRACTITIONERS (#) / STAFF (#)1-D
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
OTHER PROGRAMS ROSTER
List the names and locations of any programs that are not Teaching-Family Model and are not included on the Member TFA Program Roster for which you may provide some training, consultation, or evaluation services. Please indicate the services provided to each.
SERVICES PROVIDEDPROGRAM NAME /LOCALES / TYPE / POPULATION
SERVED / CAPACITY / TRAINING / CONSULTATION / EVALUATION
TEACHING-FAMILY ASSOCIATION
AGENCY STAFF ROSTER FOR INSERT NAME OF PROGRAM
Note: Four pages of forms are provided for staff rosters. Use separate forms for each program, titling each page by the name of the program (e.g., put Residential Group Homes, Home-Based Services, etc. where it says “insert program name” at the top of the form). If your agency needs only one or two forms, skip the extra pages and proceed to the staff resume forms.
List all agency staff that provided any of the Teaching-Family Model’s integrated services during the review year for the program listed above. Provide the person’s name, job title, date hired, and (if applicable) date terminated.Put an “X” in the appropriate box to indicate which service(s) each person provided.
Teaching-Family Services ProvidedStaff
/ Position / Date Hired (within review year) / Date Resigned or Terminated (within review year) / Adminis-tration / Training / Consul-tation / Evaluation / Agency Develop-ment1
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
AGENCY SUPPORT STAFF ROSTER FOR INSERT NAME OF PROGRAM
List all agency staff that provided any of the Teaching-Family Model’s integrated services during the review year for the program listed above. Provide the person’s name, job title, date hired, and (if applicable) date terminated.Put an “X” in the appropriate box to indicate which service(s) each person provided.
Teaching-Family Services ProvidedStaff
/ Position / Date Hired (within review year) / Date Resigned or Terminated (within review year) / Adminis-tration / Training / Consul-tation / Evaluation / Agency Develop-ment1-B
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
AGENCY SUPPORT STAFF ROSTER FORINSERT NAME OF PROGRAM
List all agency staff that provided any of the Teaching-Family Model’s integrated services during the review year for the program listed above. Provide the person’s name, job title, date hired, and (if applicable) date terminated.Put an “X” in the appropriate box to indicate which service(s) each person provided.
Teaching-Family Services ProvidedStaff
/ Position / Date Hired (within review year) / Date Resigned or Terminated (within review year) / Adminis-tration / Training / Consul-tation / Evaluation / Agency Develop-ment1-C
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
AGENCY SUPPORT STAFF ROSTER FORINSERT NAME OF PROGRAM
List all agency staff that provided any of the Teaching-Family Model’s integrated services during the review year for the program listed above. Provide the person’s name, job title, date hired, and (if applicable) date terminated. Put an “X” in the appropriate box to indicate which service(s) each person provided.
Teaching-Family Services ProvidedStaff
/ Position / Date Hired (within review year) / Date Resigned or Terminated (within review year) / Adminis-tration / Training / Consul-tation / Evaluation / Agency Develop-ment1-D
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
STAFF RESUME FORM
NAME: / DATE:POSITION/TITLE:
EMPLOYMENT HISTORY IN TEACHING-FAMILY MODEL
Beginning with your most recent work experience, please indicate which positions you have held, the dates (Month/Year) of employment within Teaching-Family programs, and the name of the Training Agency involved. Include all relevant employment such as experience as a Practitioner, Trainer, Consultant, Evaluator, or Administrator.
Dates of Employment
From / To / Position / Training Agency
RELATED TRAINING IN THE TEACHING-FAMILY MODEL
Please indicate which of the following training experiences you have had, the dates, and the location of the training. If you have had other relevant training, please describe it in the blank spaces provided.
Type of Training / Dates / Training Agency
Pre-Service Workshop Training
Advanced Workshop Training
Consultation Workshop
Evaluation Workshop
(Other - Specify Here)
(Other - Specify Here)
PRACTITIONER EVALUATION HISTORY
Please complete this section for practitioners and indicate their evaluation history.
Type of Evaluation / Date Completed / Outcome
1
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
STAFF RESUME FORM
NAME: / DATE:POSITION/TITLE:
EMPLOYMENT HISTORY IN TEACHING-FAMILY MODEL
Beginning with your most recent work experience, please indicate which positions you have held, the dates (Month/Year) of employment within Teaching-Family programs, and the name of the Training Agency involved. Include all relevant employment such as experience as a Practitioner, Trainer, Consultant, Evaluator, or Administrator.
Dates of Employment
From / To / Position / Training Agency
RELATED TRAINING IN THE TEACHING-FAMILY MODEL
Please indicate which of the following training experiences you have had, the dates, and the location of the training. If you have had other relevant training, please describe it in the blank spaces provided.
Type of Training / Dates / Training Agency
Pre-Service Workshop Training
Advanced Workshop Training
Consultation Workshop
Evaluation Workshop
(Other - Specify Here)
(Other - Specify Here)
PRACTITIONER EVALUATION HISTORY
Please complete this section for practitioners and indicate their evaluation history.
Type of Evaluation / Date Completed / Outcome
1
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
STAFF RESUME FORM
NAME: / DATE:POSITION/TITLE:
EMPLOYMENT HISTORY IN TEACHING-FAMILY MODEL
Beginning with your most recent work experience, please indicate which positions you have held, the dates (Month/Year) of employment within Teaching-Family programs, and the name of the Training Agency involved. Include all relevant employment such as experience as a Practitioner, Trainer, Consultant, Evaluator, or Administrator.
Dates of Employment
From / To / Position / Training Agency
RELATED TRAINING IN THE TEACHING-FAMILY MODEL
Please indicate which of the following training experiences you have had, the dates, and the location of the training. If you have had other relevant training, please describe it in the blank spaces provided.
Type of Training / Dates / Training Agency
Pre-Service Workshop Training
Advanced Workshop Training
Consultation Workshop
Evaluation Workshop
(Other - Specify Here)
(Other - Specify Here)
PRACTITIONER EVALUATION HISTORY
Please complete this section for practitioners and indicate their evaluation history.
Type of Evaluation / Date Completed / Outcome
1-B
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
STAFF RESUME FORM
NAME: / DATE:POSITION/TITLE:
EMPLOYMENT HISTORY IN TEACHING-FAMILY MODEL
Beginning with your most recent work experience, please indicate which positions you have held, the dates (Month/Year) of employment within Teaching-Family programs, and the name of the Training Agency involved. Include all relevant employment such as experience as a Practitioner, Trainer, Consultant, Evaluator, or Administrator.
Dates of Employment
From / To / Position / Training Agency
RELATED TRAINING IN THE TEACHING-FAMILY MODEL
Please indicate which of the following training experiences you have had, the dates, and the location of the training. If you have had other relevant training, please describe it in the blank spaces provided.
Type of Training / Dates / Training Agency
Pre-Service Workshop Training
Advanced Workshop Training
Consultation Workshop
Evaluation Workshop
(Other - Specify Here)
(Other - Specify Here)
PRACTITIONER EVALUATION HISTORY
Please complete this section for practitioners and indicate their evaluation history.
Type of Evaluation / Date Completed / Outcome
1-C
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
STAFF RESUME FORM
NAME: / DATE:POSITION/TITLE:
EMPLOYMENT HISTORY IN TEACHING-FAMILY MODEL
Beginning with your most recent work experience, please indicate which positions you have held, the dates (Month/Year) of employment within Teaching-Family programs, and the name of the Training Agency involved. Include all relevant employment such as experience as a Practitioner, Trainer, Consultant, Evaluator, or Administrator.
Dates of Employment
From / To / Position / Training Agency
RELATED TRAINING IN THE TEACHING-FAMILY MODEL
Please indicate which of the following training experiences you have had, the dates, and the location of the training. If you have had other relevant training, please describe it in the blank spaces provided.
Type of Training / Dates / Training Agency
Pre-Service Workshop Training
Advanced Workshop Training
Consultation Workshop
Evaluation Workshop
(Other - Specify Here)
(Other - Specify Here)
PRACTITIONER EVALUATION HISTORY
Please complete this section for practitioners and indicate their evaluation history.
Type of Evaluation / Date Completed / Outcome
1-D
Initial Application Materials
TEACHING-FAMILY ASSOCIATION
STAFF RESUME FORM
NAME: / DATE:POSITION/TITLE:
EMPLOYMENT HISTORY IN TEACHING-FAMILY MODEL
Beginning with your most recent work experience, please indicate which positions you have held, the dates (Month/Year) of employment within Teaching-Family programs, and the name of the Training Agency involved. Include all relevant employment such as experience as a Practitioner, Trainer, Consultant, Evaluator, or Administrator.
Dates of Employment
From / To / Position / Training Agency
RELATED TRAINING IN THE TEACHING-FAMILY MODEL
Please indicate which of the following training experiences you have had, the dates, and the location of the training. If you have had other relevant training, please describe it in the blank spaces provided.
Type of Training / Dates / Training Agency
Pre-Service Workshop Training
Advanced Workshop Training
Consultation Workshop
Evaluation Workshop
(Other - Specify Here)
(Other - Specify Here)
PRACTITIONER EVALUATION HISTORY
Please complete this section for practitioners and indicate their evaluation history.
Type of Evaluation / Date Completed / Outcome
1-E
Initial Application Materials