Team Member #3 Name: Title: Credentials: (e.g., LCSW, Ph.D., LPC, etc.): Discipline: (e.g., Social Work, Psychology, Psychiatry, Mental Health Counselor, Marriage and Family Counselor, etc.): Telephone Number: Email Address: Mailing Address: Primary Role: (Select one.) Clinical Supervisor Clinician Senior Leader Other, specify role: Secondary Role, if applicable: (Select one.) Senior Leader Clinical Supervisor Clinician Other, specify role: QUESTIONS FOR CLINICIANS AND CLINICAL SUPERVISORS CPP has been demonstrated to be efficacious with children under the age of six exposed to trauma and their primary caregivers. It is a flexible modality that can be delivered in the clinic or in the family’s home. What is the population with which you plan to implement CPP during this training? Please describe the setting(s) in the practice will be implemented, age range of the children who will receive CPP, and types of trauma the families have experienced. Describe your knowledge of early childhood development (both normal and clinical populations). What experience do you have working with infants and very young children and their caregivers? (Please indicate participation in the Infant, Early Childhood and Family Mental Health Capstone Certificate Program, equivalent training, and/or Endorsement.) What experience do you have working with adults (parents/caregivers) and families with mental health concerns and/or exposure to trauma? At present, what type of therapy does your site typically provide for families seeking treatment for their young children and/or to families seeking assistance with trauma- related symptoms or experiences? Please describe your training and experience in using evidence-based practices in mental health treatment. How do you plan to identify potential CPP clients and when will the process of identifying and screening clients for CPP begin?
Team Member #3 Name: Title: Credentials: (e.g., LCSW, Ph.D., LPC, etc.): Discipline: (e.g., Social Work, Psychology, Psychiatry, Mental Health Counselor, Marriage and Family Counselor, etc.): Telephone Number: Email Address: Mailing Address: Primary Role: (Select one.) Clinical Supervisor Clinician Senior Leader Other, specify role: Secondary Role, if applicable: (Select one.) Senior Leader Clinical Supervisor Clinician Other, specify role: QUESTIONS FOR CLINICIANS AND CLINICAL SUPERVISORS CPP has been demonstrated to be efficacious with children under the age of six exposed to trauma and their primary caregivers. It is a flexible modality that can be delivered in the clinic or in the family’s home. What is the population with which you plan to implement CPP during this training? Please describe the setting(s) in the practice will be implemented, age range of the children who will receive CPP, and types of trauma the families have experienced. Describe your knowledge of early childhood development (both normal and clinical populations). What experience do you have working with infants and very young children and their caregivers? (Please indicate participation in the Infant, Early Childhood and Family Mental Health Capstone Certificate Program, equivalent training, and/or Endorsement.) What experience do you have working with adults (parents/caregivers) and families with mental health concerns and/or exposure to trauma? At present, what type of therapy does your site typically provide for families seeking treatment for their young children and/or to families seeking assistance with trauma- related symptoms or experiences? Please describe your training and experience in using evidence-based practices in mental health treatment. How do you plan to identify potential CPP clients and when will the process of identifying and screening clients for CPP begin?
CPP-Application-Form-2018.docx