Trauma-Informed Care Consortium (TICC) of Central Texas

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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: *

Job title: *

Phone number: *

Email: *

Name of secondary staff member:

Job title:

Phone number:

Email:

Name of Agency: *

Agency phone number: *

Website: *

Physical address: *

Is your organization a... *

Non-profit

For-profit

Other:

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.) *

Please check if you are providing ACGC with permission to publish your agency information on the TICC website (www.traumatexas.com): *

Yes

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.)

What does your agency hope to gain from its participation in the TICC? *

What types of resources (e.g., expertise, meeting space, supplies, training, etc.) will your agency contribute to the TICC? *

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.

Please check all that apply to your agency (if none apply, please feel free to skip this question):

Trauma-informed policy (If so, please send to ticc@austinchildguidance.org)

Policy against use of restraint and seclusion

Provide written informed consent to all clients

Survey clients on their sense of choice and options for treatment

Survey clients on experience and satisfaction with services

Survey clients about their perception of safety in your agency’s physical environment

Policy or procedure to support staff that experience trauma or secondary trauma

Provide a trauma screener to ALL clients

Collect data related to trauma

Provide trauma training to ALL staff (including board members, administrative staff, and volunteers)

Provide evidence based trauma informed interventions

Provide annual training on cultural sensitivity to ALL staff members (including board members, administrative staff, and volunteers)

Other:

If your agency screens clients for trauma, what is the name of the screener used?

Ex. CPSS, UCLA PTSD, agency developed, etc.

Who completes the trauma screener?

All Clients

Most Clients (more than 50% of clients)

Some Clients (less than 50% of clients)

No Clients

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If your agency provides evidence based trauma-informed interventions, what type of invention do you use?

Ex. TF-CBT, DBT, PCIT, etc.

Check any committees you are interested in participating in:

Newsletter committee

Website development committee

Marketing and outreach committee

Trauma screening workgroup

Is there any additional information you would like to share with us about your agency?

Name of person completing this application: *

Submit

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