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* Agency/Provider Name

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* Name of Person Completing Questionnaire

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* Email Address/Phone Number of Provider

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* Please select the region/area provider represents.

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* Please provide the name of the location (city, county, municipality, township, etc).

Evidence-Based Best Practices

Please list 1-3 evidence-based best practices that you currently use and check the list of items describing those practices.

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* Evidence-Based Best Practices #1

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* 1a. Identify the youth serving system for Best Practice #I.

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* 1b. Select the clinical types provided for Best Practice #I. Please select all that apply.

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* 1c. Identify the setting for Best Practice # I.

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* 1d. Identify the geographic area served for Best Practice # I.

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* 1e. Identify the age group the program targets for Best Practice #I.

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* 1f. Total Program Cost for Best Practice #I.

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* Evidence-Based Best Practices #2

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* 2a. Identify the youth serving system for Best Practices #2.

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* 2b. Select the clinical types provided for Best Practices #2. Please select all that apply.

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* 2c. Identify the setting for Best Practices #2.

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* 2d. Identify the geographic area served for Best Practices #2.

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* 2e. Identify the age group served for Best Practices #2.

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* 2f. Total Program Cost for Best Practices #2.

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* Evidence-Based Best Practices #3

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* 3a. Identify the youth serving system for Best Practice #3.

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* 3b. Select the clinical types provided for Best Practice #3. Please select all that apply.

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* 3c. Identify the setting for Best Practice #3.

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* 3d. Identify the geographic area served for Best Practices #3.

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* 3e. Identify the age group for Best Practices #3.

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* 3f. Total Program Cost for Best Practices #3.

Community-Support Best Practices

Please identify 1-3 community-support best practices that you currently use and check the list of items describing those practices.

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* Community Support Best Practices #1

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* 1a. Identify the community setting for Best Practice #1.

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* 1b. Identify the geographic area served for Community Support Best Practices #1.

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* 1c. Total Program Cost for Community Support Best Practices #1.

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* Community Support Best Practices #2

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* 2a. Identify the community setting for Best Practice #2.

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* 2b. Identify the geographic area served for Community Support Best Practices #2.

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* 2c. Total Program Cost for Community Support Best Practices #2.

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* Community Support Best Practices #3

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* 3a. Identify the community setting for Best Practice #3.

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* 3b. Identify the geographic area served for Community Support Best Practices #3.

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* 3c. Total Program Cost for Community Support Best Practices #3.

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* Please use space below for further explanation.

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