North Carolina Child Welfare Trauma-Informed Assessment-Leadership

North Carolina Child Welfare Trauma-Informed Assessment

Provider Application: Leadership
First & Last Name*
Agency Name*
Job Title*
Agency Website*
Provide Link to Agency Site
Email for Application Correspondence*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Agency Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Please indicate the number of practice sites/locations where services are provided.*
How many locations will be represented on your proposed assessment team? *
Provide the city/cities of your proposed team’s practice sites.*
YesNoIn the process
If you are in the process, indicate your anticipated completion date.
Please list your proposed team members. Each team must include at least one Clinical Team Lead (CTL). For each CTL and clinician applicant, provide the following information:*
Organizational Support
Briefly describe the agency's mission and primary services.*
Describe your internal procedures and timeline for responding to referrals.*
Indicate the number of Child Welfare Trauma-Informed Assessments the agency expects to complete annually.*
Please describe how your agency measures the effectiveness of services provided.*
Region 1Region 2Region 3Region 4Region 5Region 6Region 7
Which counties within the region(s) is the agency able to serve?*
Telehealth assessments will be permitted when in-person assessment is otherwise not feasible. How does your agency plan to ensure service accessibility for youth who are not appropriate candidates for telehealth?*
Commitment to Trauma-Informed Care
Describe your agency's commitment to trauma-informed care. How is this reflected in your agency’s policies, procedures, and values? If not already demonstrated, describe your agency's plan to develop trauma-informed polices, procedures, and values.*
What trauma-informed evidence-based practices/therapies (EBP/Ts), evidence informed, and/or promising practices has your agency previously implemented? What challenges and successes were encountered?*
Are there other evidence-informed training models or practices previously implemented by your agency? *
How will leadership support the adoption or adjustment of trauma-informed practices/policies to support your agency's implementation of the CWTIA. Please describe your agency’s readiness and commitment.*
Support for Clinical Team Leads & Clinicians
How does your agency currently ensure clinicians have protected time to complete assessments? Each CWTIA may take 6+ hours (including face-to-face time, collateral contacts, and writing, excluding clinical coaching). How will your agency protect clinicians’ time to complete this work?*
What systems or supports does your agency have in place to provide ongoing oversight of clinicians’ trauma-informed work?*
What systems or supports does your agency have or plan to put in place to provide ongoing oversight of clinicians’ trauma-informed work?*
Communities of Practice (CoP) meetings are designed to strengthen coordination across systems to better support children and families involved in child welfare. The goal is to improve access to trauma-informed assessments, address service delivery barriers, foster cross-agency collaboration, and enhance referral pathways to community resources. Cross-system CoP participants include NC DHHS DSS representatives, county DSS/child welfare, provider agencies, health plan representatives, and individuals with lived experience. Meetings will be held virtually each quarter and are expected to last 60–90 minutes. How will you ensure your agency's ongoing and consistent participation in CoP meetings for the regions you are selected to provide CWTIA services for?*
Collaboration with Local DSS Offices
Do you currently have relationships or contracts to provide services with any DSS offices in the regions where you have applied? If so, please list the county and briefly describe the relationship or contract.*
How does your leadership team foster collaboration between your agency and county DSS offices?*
Do you foresee any challenges in collaborating with county DSS partners? If so, how might your agency address them?*
Implementation Leadership Scale (ILS)

The ILS assesses the degree to which a leader is Proactive, Knowledgeable, Supportive, and Perseverant in regard to evidence-based practice implementation.
Proactive
I have developed a plan to facilitate implementation of evidence-based practice*
I have removed obstacles to the implementation of evidence-based practice*
I have established clear department standards for the implementation of evidence- based practice*
Knowledgeable
I am knowledgeable about evidence-based practice*
I am able to answer staff’s questions about evidence-based practice*
I know what I am talking about when it comes to evidence-based practice*
Supportive
I recognize and appreciate employee efforts toward successful implementation of evidence-based practice*
I support employee efforts to learn more about evidence-based practice*
I support employee efforts to use evidence-based practice*
Perserverant
I persevere through the ups and downs of implementing evidence-based practice*
I carry on through the challenges of implementing evidence-based practice*
I react to critical issues regarding the implementation of evidence-based practice by openly and effectively addressing the problem(s)*
Signature*

Powered by Jotform SignClear
Please ensure all information is accurate and complete prior to submission. Once submitted, applications cannot be reopened or revised.
Should be Empty:

North Carolina Child Welfare Trauma-Informed Assessment

Organizational Support

Commitment to Trauma-Informed Care

Support for Clinical Team Leads & Clinicians

Collaboration with Local DSS Offices

Implementation Leadership Scale (ILS)

Proactive

Knowledgeable

Supportive

Perserverant

Please ensure all information is accurate and complete prior to submission. Once submitted, applications cannot be reopened or revised.