North Carolina Child Welfare Trauma-Informed Assessment-Clinical Team Lead

North Carolina Child Welfare Trauma-Informed Assessment

Provider Application: Clinical Team Lead
First & Last Name*
Agency Name*
Job Title*
Practice Site/Office Location*
City
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 or locations for which you will provide oversight of the Child Welfare Trauma-Informed Assessment (CWTIA).*
Please list the city(ies) of your proposed practice sites where you will be providing oversight for this assessment. *
Please indicate how many trauma-informed assessment clinicians you plan to provide oversight and fidelity monitoring.*
A Clinical Team Lead (CTL) OnlyA CTL & CWTIA clinician
Licensure & Credentialing
LMFTLCSWLPCLCMHCLCASLicensed PsychologistTribal / IHS / 638 (Federal licensure authority)Other
License Number*
Experience in Oversight
Please describe your professional background and qualifications relevant to providing clinical oversight.*
How do you provide feedback and coaching to clinicians to support skill development and continuous quality improvement?*
How do you currently ensure that clinical work is aligned with best practices or EBP/Ts?*
Fidelity Monitoring and Capacity
Does your agency have internal monitoring processes for clinical work? If so, please describe them. If not, please indicate your willingness or capacity to adopt them for the NC CWTIA.*
What is your plan to maintain capacity for timely access to this assessment?*
How will you communicate successes and challenges with your leadership team? *
Collaboration and Coordination
Communities of Practice (CoP) meetings strengthen coordination across systems to support children and families in child welfare by improving access to trauma-informed assessments, addressing service barriers, fostering collaboration, and enhancing referral pathways. Participants include county DSS, provider agencies, NCDHHS DSS, health plans, and individuals with lived experience. These meetings focus on implementation barriers and sustainability and are best suited for participation by the Clinical Team Lead (CTL) or an agency leader familiar with CWTIA implementation. As the agency’s Clinical Team Lead (CTL), how will you use insights gained from the Communities of Practice (CoP) meetings to strengthen agency oversight and promote ongoing quality improvement? *
How does your agency currently foster collaboration between clinicians and county DSS offices?*
Support for Clinicians
Each NC CWTIA typically requires six or more hours to complete, including the in-person interview, collateral contacts, and report writing. How will your agency support clinicians in managing this time commitment while balancing other clinical responsibilities? *
How will you provide feedback and ensure ongoing skill development related to trauma-informed care?*
Please describe your plan for providing oversight to clinicians conducting assessments. *
Professional and Ethical History
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If you answered “yes” to any of the questions regarding prior professional or ethical issues, please provide a written explanation outlining the circumstances, relevant dates, outcomes, andany corrective actions taken. Please include supporting documentation from the licensing board or other relevant entities. Emails may be sent to sroberts@benchmarksnc.org .
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*

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Please ensure all information is accurate and complete prior to submission. Once submitted, applications cannot be reopened or revised.
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North Carolina Child Welfare Trauma-Informed Assessment

Licensure & Credentialing

Experience in Oversight

Fidelity Monitoring and Capacity

Collaboration and Coordination

Support for Clinicians

Professional and Ethical History

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.