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Community Child Care Resources, Inc. Psychological Services Children's Services Advisory Committee a. PROGRAM EVALUATION (Entire Section F not to exceed two pages) 2 DEMOGRAPHICS : What information (data elements) will you need - to collect in order to accurately describe your target population including demographics (age, gender, and ethnic background) required by the funder in Section H? What are the pieces of information that qualify them for your target population? How do you document their need for services or their "unacceptable condition requiring change" from Section Bl ? Data Elements Describing "Services to Families " Target Population: a. Source of referral — (center, parent, CCCR, outside agency) b. Form of treatment plan — (child, parent, couple, family) c. Diagnostic code (DX) number d. Admission Global Assessment of Functioning (GAF) number e. Anticipated number of service units that will be needed Data Elements Describing "Services to Classrooms " target Population - a. Number of children exhibiting behavioral concerns b. Number of children scoring below standard norms on DECA assessment C, Type and number of unsuccessful teacher interventions prior to requesting services d. Type and number of teacher requests for service in individual centers e. Number of service units used per classroom f. Number of children referred for individual therapy 2. MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D? What tools or items are you using as measures (grades, survey scores, attendance, absences, skill levels) for your program ? Are you getting baseline information from a source on your Collaboration List in Section E ? Are there results from your Activities in Section D that need to be documented ? How often do you need to collect or follow-up on this data ? Services to Families " Measurement Elements a. The number of referrals made for psychological services will be collected by the Family Resource Coordinator (FRC) and compiled in the Psychological Services Log. b . Mental Health Provider Forms completed by the therapist will be collected quarterly and compiled in the Psychological Services Log. The form documents admission and discharge GAF ' s, Diagnosis Codes and descriptions, # of appointments made, kept, cancelled and "no Show", anticipated length of treatment, and other outside resources being used. Services to Classrooms " Measurement Elements a. Fall and spring DECA assessment scores will be collected. in November and May and compiled in the Psychological Services Log. b . The numbers and types of classroom concerns are collected through the completion of the Teacher Observation Forms. They are submitted along with the Psychological Support Classroom Report Form to the FRC who compiles them in the psychological Services log. c. The Psychological Support Classroom Report form is completed by the therapist and submitted to the FRC (compiled in Psychological Services Log) . This form documents type and severity of behavioral concerns observed, description of strategies to be implemented, and the expected need for follow-up by the therapist to the classroom. Application for 2004-2005 service period 11