The Core Team Is Expected To

Part 2: Collaborative Application Form

T r a u m a - F o c u s e d C o g n i t i v e B e h a v i o r a l T h e r a p y ( T F - C B T ) L e a r n i n g C o l l a b o r a t i v e A p p l i c a t i o n P a c k e t

Site Contact Information

Enter the Agency/ Site Name:

Information for completing site contact information  Teams are comprised of three to five members.

 A team needs to include at least ONE senior leader, ONE clinical supervisor, and ONE clinician.

 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, “trainer.”) 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.

 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.

 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 (i.e. who will not attend the learning sessions etc.).

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: ______

Collaborative Application Form 1 of 11 Team Member #1

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

Primary Role: (Select one 1.) 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

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 #3

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

1 To check a box, double click on the box and select Checked under Default value.

Collaborative Application Form 2 of 11 Team Member #4:

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

Team Member #5

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

Team Member #6 (OPTIONAL)

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

Collaborative Application Form 3 of 11 Team Member #7 (OPTIONAL)

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

Team Member #8 (OPTIONAL)

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

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:

Collaborative Application Form 4 of 11 Description of Agency, Team, Implementation Plans, and Experience

Instructions for completing this section  Answer all of the questions directly on this form.  Please be succinct as the goal is to get a general sense your organization, including implementation plans and experience in areas relevant to this LC.  Consider getting input from all the members of your proposed team.

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.

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 posttraumatic stress disorder (PTSD). This treatment model may not be ideally suited for children whose primary presentation is for severe or preexisting behavioral disruptions. Typically TF-CBT is utilized in outpatient settings where there is a caregiver 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).

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 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 the Part I of the Application Packet, clinicians and supervisors participating in the LC are expected to begin providing TF-CBT by late March/early April. 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. Describe any previous experience the agency and team members have had implementing TF-CBT. For example, is TF-CBT currently being used in other programs in the agency? If your agency or team has not previously provided TF-CBT, describe any prior experience your agency and team members have had using treatments guided by a manual.

Collaborative Application Form 5 of 11 6. As previously noted, the agency must administer the NCTSN Core Data Set to all children receiving TF-CBT at the start and end of treatment and submit de-identified assessment data (using the InForm system or data transfer). Is your agency currently utilizing and submitting data to the Core Data Set? If not, please describe your agency’s plan and timeline to begin implementation of the Core Data Set.

7. What are the key challenges your organization faces implementing and sustaining the use of TF-CBT at your agency? Areas to consider include (1) level of support from staff at all levels of the agency, particularly senior leadership; (2) capacity to identify and screen referrals; (3) experience using standardized assessments to evaluate client progress; (4) agency commitment to providing ongoing supervision in evidence-based practices; and (5) capacity to continue to monitor progress toward adoption of TF-CBT, including treatment fidelity. .

Collaborative Application Form 6 of 11 Team Expectations

Instructions for completing team expectations  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 proposed solutions.  Consider completing this portion of the application as a team (either in a face-to-face format or through synthesizing feedback from each team member).  “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 :  Participate in pre-work calls and activities including completion of:  Pre-work measures, including an organizational assessment to identify systemic challenges and set site-specific goals; and  Any tasks necessary to implement the NCTSN Core Data Set.

Yes No/Not sure Challenges and proposed solutions:

 Attend three, two-day learning sessions and complete assignments to prepare for the learning sessions.

Yes No/Not sure Challenges and proposed solutions:

 Meet as a team at least once per month to evaluate progress (e.g., review metrics), identify challenges, and discuss next steps for practice and system improvements.

Yes No/Not sure Challenges and proposed solutions:

 Participate in the collaborative evaluation including:  Completing questionnaires (e.g., to provide feedback about the LC experience);  Participating in a focus group (at Learning Session 3).

Yes No/Not sure Challenges and proposed solutions:

 Use the collaborative intranet to:  Obtain information and materials for the collaborative;  Communicate with faculty and other teams (e.g., posting questions about practice on the discussion board so other teams can contribute to and benefit from the discussion); and  Post materials and information (e.g., results of tests of change) so that your team’s improvements and lessons learned can benefit others.

Collaborative Application Form 7 of 11 Yes No/Not sure Challenges and proposed solutions: All clinicians on our team will:  As pre-work for Learning Session 1, complete on-line training (TF-CBTWeb). This expectation does not apply to clinicians who have already had basic training in TF-CBT.

Yes No/Not sure