Trauma-Informed Care Consortium (TICC) of Central Texas - Membership Application
Selection Process:
Members are selected based on their commitment to trauma-informed (TI) work, while also ensuring that we have a cross-discipline and diverse membership that is working towards utilizing more trauma-informed practices. If your agency is not selected to be an official member, participation and attendance at quarterly meetings is still encouraged.

Member Requirements:
• Completed and submit a membership application;
• Designate one primary and one alternate staff member (these two members can vote on behalf of the agency);
• Have primary staff member or designated alternate staff member attend 3 of the 4 quarterly meetings;
• Contribute resources to the TICC (e.g., expertise, meeting space, supplies, training, etc.);
• Provide documentation of progress towards your agencies efforts to become or maintain TI care status;
• Complete a new membership application form if there are changes in primary or alternate staff members;
• Complete annual Trauma-Informed Care Organizational Readiness Survey.

Name of primary staff member: *
Your answer
Job title: *
Your answer
Phone number: *
Your answer
Email: *
Your answer
Name of secondary staff member:
Your answer
Job title:
Your answer
Phone number:
Your answer
Email:
Your answer
Name of Agency: *
Your answer
Agency phone number: *
Your answer
Website: *
Your answer
Physical address: *
Your answer
Is your organization a... *
Please provide a description of your agency (up to three/four sentences), describing the services offered. (Please provide exact wording, as it will appear on website, newsletters, etc.) *
Your answer
Please check if you are providing ACGC with permission to publish your agency information on the TICC website (www.traumatexas.com): *
Please list any steps your agency has taken to become trauma-informed. (If your organization has not taken any steps please feel free to skip this question.)
Your answer
What does your agency hope to gain from its participation in the TICC? *
Your answer
What types of resources (e.g., expertise, meeting space, supplies, training, etc.) will your agency contribute to the TICC? *
Your answer
Please list any trauma trainings that your agency offers, including the title of the training, a brief description, and the intended audience.
For example, “Overcoming Trauma” is a workshop provided by ACGC for parents to help them identify trauma, understand the causes, and explores ways to help children.
Your answer
Please check all that apply to your agency (if none apply, please feel free to skip this question):
If your agency screens clients for trauma, what is the name of the screener used?
Ex. CPSS, UCLA PTSD, agency developed, etc.
Your answer
Who completes the trauma screener?
If your agency provides evidence based trauma-informed interventions, what type of invention do you use?
Ex. TF-CBT, DBT, PCIT, etc.
Your answer
Check any committees you are interested in participating in:
Is there any additional information you would like to share with us about your agency?
Your answer
Name of person completing this application: *
Your answer
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