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Community Child Care Resources, Inc. Psychological Services Children's Services Advisory Committee <br /> a. PROGRAM EVALUATION (Entire Section F not to exceed two pages) <br /> 2 DEMOGRAPHICS : What information (data elements) will you need to collect in order to <br /> accurately describe your target population including demographics (age, gender, and ethnic <br /> background) required by the funder in Section H? What are the pieces of information that <br /> qualify them for your target population ? How do you document their need for services or <br /> their "unacceptable condition requiring change" from Section B19 <br /> Data Elements Describing "Services to Families " Target Population <br /> a. Source of referral — (center, parent, CCCR, outside agency) <br /> b . Form of treatment plan — (child, parent, couple, family) <br /> c . Diagnostic code (DX) number <br /> d . Admission Global Assessment of Functioning (GAF) number <br /> e. Anticipated number of service units that will be needed <br /> Data Elements Describing "Services to Classrooms " target Population <br /> a. Number of children exhibiting behavioral concerns <br /> b. Number of children scoring below standard norms on DECA assessment <br /> C, Type and number of unsuccessful teacher interventions prior to requesting services <br /> d. Type and number of teacher requests for service in individual centers <br /> e. Number of service units used per classroom <br /> f. Number of children referred for individual therapy <br /> 2. MEASURES : What data elements will you need to collect to show that you have achieved <br /> (or made progress toward) your Measurable Outcomes in Section D ? What tools or items <br /> are you using as measures (grades, survey scores , attendance, absences , skill levels) for your <br /> program ? Are you getting baseline information from a source on your Collaboration List in <br /> Section E ? Are there results from your Activities in Section D that need to be documented ? <br /> How often do you need to collect or follow-up on this data ? <br /> Services to Families " Measurement Elements <br /> a. The number of referrals made for psychological services will be collected by the Family Resource <br /> Coordinator (FRC) and compiled in the Psychological Services Log <br /> b Mental Health Provider Forms completed by the therapist will be collected quarterly and compiled <br /> in the Psychological Services Log . The form documents admission and discharge GAF ' s , Diagnosis <br /> Codes and descriptions, # of appointments made , kept, cancelled and "no Show", anticipated length <br /> of treatment, and other outside resources being used . <br /> Services to Classrooms " Measurement Elements <br /> a. Fall and spring DECA assessment scores will be collected in November and May and compiled in <br /> the Psychological Services Log . <br /> b . The numbers and types of classroom concerns are collected through the completion of the <br /> Teacher Observation Forms . They are submitted along with the Psychological Support Classroom <br /> Report Form to the FRC who compiles them in the psychological Services log . <br /> c. The Psychological Support Classroom Report form is completed by the therapist and submitted to <br /> the FRC (compiled in Psychological Services Log) . This form documents type and severity of <br /> behavioral concerns observed, description of strategies to be implemented, and the expected need <br /> for follow-up by the therapist to the classroom. <br /> Application for 2005 -2006 service period 11 <br />