Exit this survey

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* Your TCTY ID #

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* Reporting period:

Date

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* I. How much consultation in TF-CBT did you receive from the TCTY (e.g., through participation in conference calls) during the past month? ( Check only one)

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* II. How much supervision in TF-CBT did you receive during the past month? Include individual, group, or peer supervision with TF-CBT cases and guidance in TF-CBT components/skills that you received though your agency. Do not include consultation in TF-CBT received from TCTY Trainers. (Check only one)

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* Check here if you had no open TF-CBT cases anytime this month in which case you do not need to complete the remainder of this form.

III. Please complete the table below for clients who, during the past month, (1) received one or more sessions of TF-CBT or (2) terminated TF-CBT (i.e., dropped out of or completed TF-CBT). Remember to delete client identifiers before submitting. *Count as one TF-CBT session 1) a session where you met individually with the child only, 2) a session where you met individually with the child and also met individually with his/her caregiver, or 3) a session where you met individually with the child (or caregiver) and also met conjointly with the child and caregiver. If you only saw 1 client, you only need to fill out '#1' questions.
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#1: TCTY Client ID#
#1: Check if client began TF-CBT before 2/1/11
#1: Number of TF-CBT sessions received this past month*

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#1: No. of time-met/spoke individually with caregiver or met conjointly with child & caregiver-for 15 min.or more in the past month.
#1: Treatment Status as of the end of this reporting period/past month

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#2: TCTY Client ID#
#2: Check if client began TF-CBT before 2/1/11
#2: Number of TF-CBT sessions received this past month*

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#2: No. of time-met/spoke individually with caregiver or met conjointly with child & caregiver-for 15 min.or more in the past month.
#2: Treatment Status as of the end of this reporting period/past month

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#3: TCTY Client ID#
#3: Check if client began TF-CBT before 2/1/11
#3: Number of TF-CBT sessions received this past month*

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#3: No. of time-met/spoke individually with caregiver or met conjointly with child & caregiver-for 15 min.or more in the past month.
#3: Treatment Status as of the end of this reporting period/past month

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#4: TCTY Client ID#
#4: Check if client began TF-CBT before 2/1/11
#4: Number of TF-CBT sessions received this past month*

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#4: No. of time-met/spoke individually with caregiver or met conjointly with child & caregiver-for 15 min.or more in the past month.
#4: Treatment Status as of the end of this reporting period/past month

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#5: TCTY Client ID#
#5: Check if client began TF-CBT before 2/1/11
#5: Number of TF-CBT sessions received this past month*

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#5: No. of time-met/spoke individually with caregiver or met conjointly with child & caregiver-for 15 min.or more in the past month.
#5: Treatment Status as of the end of this reporting period/past month

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* Check here if you did not provide TF-CBT this month:

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* IV. Please choose the response that best describes your understanding and skill in implementing each of the specified components of TF-CBT during the past month.

  Did not use Minimal Minimal to moderate Moderate Moderate to advanced Advanced
1. Psychoeducation (e.g., directive education about normal reactions to trauma)
2. Parenting Skills (e.g., time out, praise, selective attention, reinforcement plans)
3. Relaxation (explained physiology of relaxation and/or instructed on relaxation methods)
4. Affective Expression (assisted child in accurately identifying feelings) and Regulation (e.g., using imagery, positive self-talk)
5. Cognitive Coping and Processing (e.g., educating child on "cognitive triangle")
6. Trauma Narrative (developing and working with child to modify cognitive distortions thoughout narrative)
7. In Vivo Exposure (worked on in-vivo desensitization plan to resolve avoidant behaviors)
8. Conjoint Parent-Child Treatment (shared trauma narrative or other conjoint activity)
9. Enhanced Safety Skills (e.g., developed a safety plan)

T