North Carolina Child Welfare Trauma-Informed Assessment-Clinician

North Carolina Child Welfare Trauma-Informed Assessment

Provider Application: Clinician
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
Licensure & Credentialing
LMFTLMFTALCSWLCSWALPCLPCALCMHCLMCHCALCASLCASALicensed PsychologistLicensed Psychological AssociateTribal / IHS / 638 (Federal licensure authority)Other
License Number*
National Provider Identifier (NPI) Number*
YesNoIn the process
Alliance HealthAmeriHealth CaritasCarolina Complete HealthHealthy BlueHealthy Blue Care Together (Children & Families Specialty Plan)Eastern Band of Cherokee Indians (EBCI) Tribal OptionUnitedHealthcare Community PlanPartners Health ManagementTrillium Health ResourcesWellCare Of NCVaya HealthOther
If you are in the process of becoming paneled with any of the listed health plans, please provide the name and anticipated date of completion.
Experience with Standardized Clinical Assessment
Please indicate any standardized assessment measures that you regularly use in your clinical practice.*
Briefly describe how you use standardized assessment data in your clinical practice.*
Briefly describe your strategy for screening and assessing a child’s trauma history and symptoms (including PTSD).*
Time Commitment
Each assessment may take 6 or more hours to complete, including face-to-face time, collateral contacts, and writing (excluding clinical coaching). How will you manage the time commitment required for conducting trauma-informed assessments?*
What plans or supports have you and your leadership and/or clinical team lead discussed to help you successfully complete assessments?*
Collaborating with Child Welfare Agencies
Describe your current or previous experience collaborating with county DSS offices in your clinical work.*
What strategies do you use to effectively communicate and coordinate services with child welfare agencies?*
Experience with Child Welfare–Involved Youth and Families
Please indicate your experience working with child welfare–involved youth and families.*
Training & Experience
Describe your experience with evidence-based, evidence-informed and promising practices.*
What successes and/or challenges have you faced in implementing these practices in your clinical work?*
Have you attended any trauma-informed trainings, or do you hold any trauma-informed certifications? If so, please list them.*
Proficiency Documentation & Proof of Completion
Please review the proficiency requirements below and upload documentation showing completion.

Determination of whether a training meets proficiency requirements is at the discretion of the purveyor.

Your proof of completion must include:
- A certificate confirming completion of the training, and
- A training agenda and/or learning objectives that clearly show how the training aligns with the identified proficiency area.
You must meet all pre-requisite proficiencies before applying. Proof of post-training proficiencies is required within the listed timeframe. Information regarding submission of post-training proficiencies will be provided during assessment training for selected providers.
Trauma-Informed Clinical Practice (Pre-requisite)
YesNo
You must complete this proficiency prior to applying. Please delay submission until this pre-requisite is met
Upload proof of training completion (e.g., certificate, agenda, or learning objectives).*

Cancelof
Briefly describe how this training met the required proficiency.*
Child Development & Disruption (Pre-requisite)
YesNo
You must complete this proficiency prior to applying. Please delay submission until this pre-requisite is met
Upload proof of training completion (e.g., certificate, agenda, or learning objectives).*

Cancelof
Briefly describe how this training met the required proficiency.*
Child Welfare & System Involvement (Pre-requisite)
YesNo
You must complete this proficiency prior to applying. Please delay submission until this pre-requisite is met
Upload proof of training completion (e.g., certificate, agenda, or learning objectives).*

Cancelof
Briefly describe how this training met the required proficiency.*
Assessment & Standardized Measures (3-Month Requirement)
YesNo
Information regarding submission of post-training proficiencies will be provided during assessment training for selected providers.
Upload proof of training completion (e.g., certificate, agenda, or learning objectives).

Cancelof
Briefly describe how this training met the required proficiency.
Personal History & Contextual Awareness (3-Month Requirement)
YesNo
Information regarding submission of post-training proficiencies will be provided during assessment training for selected providers.
Upload proof of training completion (e.g., certificate, agenda, or learning objectives).

Cancelof
Briefly describe how this training met the required proficiency.
Developmentally Informed Engagement (6-Month Requirement)
YesNo
Information regarding submission of post-training proficiencies will be provided during assessment training for selected providers.
Upload proof of training completion (e.g., certificate, agenda, or learning objectives).

Cancelof
Briefly describe how this training met the required proficiency.
Secondary Traumatic Stress Awareness & Mitigation (6-Month Requirement)
YesNo
Information regarding submission of post-training proficiencies will be provided during assessment training for selected providers.
Upload proof of training completion (e.g., certificate, agenda, or learning objectives).

Cancelof
Briefly describe how this training met the required proficiency.
Acknowledgment Section
I attest that the information provided above is accurate to the best of my knowledge.I understand that all pre-requisite proficiencies must be completed before applying.
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
The agency I am a part of has developed a plan to facilitate implementation of evidence-based practice*
The agency I am a part of has removed obstacles to the implementation of evidence-based practice*
The agency I am a part of has established clear department standards for the implementation of evidence-based practice*
Knowledgeable
The agency I am a part of is knowledgeable about evidence-based practice*
The agency I am a part of is able to answer my questions about evidence-based practice*
The agency I am a part of knows what he or she is talking about when it comes to evidence- based practice*
Supportive
The agency I am a part of recognizes and appreciates employee efforts toward successful implementation of evidence-based practice*
The agency I am a part of supports employee efforts to learn more about evidence-based practice*
The agency I am a part of supports employee efforts to use evidence-based practice*
Perserverant
The agency I am a part of perseveres through the ups and downs of implementing evidence-based practice*
The agency I am a part of carries on through the challenges of implementing evidence-based practice*
The agency I am a part of reacts 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 with Standardized Clinical Assessment

Time Commitment

Collaborating with Child Welfare Agencies

Experience with Child Welfare–Involved Youth and Families

Training & Experience

Proficiency Documentation & Proof of Completion

Trauma-Informed Clinical Practice (Pre-requisite)

Child Development & Disruption (Pre-requisite)

Child Welfare & System Involvement (Pre-requisite)

Assessment & Standardized Measures (3-Month Requirement)

Personal History & Contextual Awareness (3-Month Requirement)

Developmentally Informed Engagement (6-Month Requirement)

Secondary Traumatic Stress Awareness & Mitigation (6-Month Requirement)

Acknowledgment Section

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.