Criterion - Wisconsin Office of Children's Mental Health



Domain 1. Program Procedures and Settings: “To what extent are program activities and settings consistent with five core values of trauma-informed cultures of care: safety, trustworthiness, choice, collaboration, and empowerment?”

Domain 1A. Safety for Consumers—Ensuring Physical and Emotional Safety: “To what extent do the program’s activities and settings ensure the physical and emotional safety of consumers?”

|Criterion |1 |2 |3 |4 |5 |

|1. Physical Setting Review: The program has conducted a specific and |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|systematic review of its physical setting (including signs, waiting areas, |review has been |review has been conducted,|action plan to maximize |action plan has been |steps of the action plan |

|offices, restrooms, outside spaces) in order to evaluate its physical and |conducted. |incl. consumer-survivor |consumer safety has been |partially implemented. |have been implemented. |

|emotional safety and to make changes necessary to ensure consumer safety. | |and all staff input. |developed. | | |

|2. Interpersonal Contacts Review: The program has conducted a specific and|No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|systematic review of its interpersonal contacts, relationships, and |review has been |review has been conducted,|action plan to maximize |action plan has been |steps of the action plan |

|activities in order to evaluate their physical and emotional safety and to |conducted. |incl. consumer-survivor |consumer safety has been |partially implemented. |have been implemented. |

|make changes necessary to ensure consumer safety. This review has included | |and all staff input. |developed. | | |

|all staff (support, direct service, and administrative) and all contacts. | | | | | |

|3. Incident Review: The program systematically reviews those incidents that|No incident reviews have|A plan has been developed |In addition to (2), a plan|In addition to (3), the |In addition to (4), the |

|indicate a lack of consumer safety (e.g., verbal and physical |occurred. |for identifying and |has been developed for |plan has been implemented.|incident reviews are used |

|confrontations, assaults) and makes changes to prevent their recurrence. | |reporting incidents that |clinical and | |to modify potentially |

| | |indicate a lack of safety |administrative review of | |unsafe practices or |

| | |based on consumer reports.|incidents that indicate a | |settings. |

| | | |lack of safety. | | |

|4. Consumer Ratings of Safety: In program satisfaction surveys, consumers |No consumers rate |Fewer than 40% of |40-70% of consumers rate |71-90% of consumers rate |More than 90% of consumers|

|rate program safety at the “agree” (or comparable, better than neutral) |program safety at the |consumers rate program |program safety at the |program safety at the |rate program safety at the|

|point on the rating scale or higher. |“agree” or higher point.|safety at the “agree” or |“agree” or higher point. |“agree” or higher point. |“agree” or higher point. |

| | |higher point. | | | |

Domain 1B. Trustworthiness for Consumers —Maximizing Trustworthiness through Task Clarity, Consistency, and Interpersonal Boundaries: “To what extent do the program’s activities and settings maximize trustworthiness by making the tasks involved in service delivery clear, by ensuring consistency in practice, and by maintaining boundaries that are appropriate to the program?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its physical setting and activities in order to evaluate factors |review has been |review has been conducted,|action plan to maximize |action plan has been |steps of the action plan |

|related to program trustworthiness (esp. clear tasks, consistent practices, |conducted. |including |program trustworthiness |partially implemented. |have been implemented. |

|and staff-consumer boundaries) and to make changes necessary to ensure that | |consumer-survivor input. |has been developed. | | |

|trustworthiness is maximized. (Peer-run programs have different boundary | | | | | |

|concerns than those with professional staffs; they need to adjust the | | | | | |

|understanding of trustworthiness accordingly.) | | | | | |

|2. Informed Consent: The program reviews its services with each |No consumers have |Fewer than 30% of |30-60% of consumers have |61-90% of consumers have |More than 90% of consumers|

|prospective consumer, based on clear statements of the goals, risks, and |provided informed |consumers have provided |provided informed consent.|provided informed consent.|have provided informed |

|benefits of program participation, and obtains informed consent from each |consent. |informed consent. | | |consent. |

|consumer. | | | | | |

|3. Review of Alleged Boundary Violations: The program has a clear procedure|No policy exists |A plan has been developed |In addition to (2), a plan|In addition to (3), the |In addition to (4), the |

|for the review of any allegations of boundary violations, including sexual |regarding review of |for identifying and |has been developed for |plan has been implemented.|incident reviews are used |

|harassment and inappropriate social contacts. |alleged boundary |reporting incidents that |clinical and | |to modify practices that |

| |violations. |indicate possible boundary|administrative review of | |may lead to boundary |

| | |violations. |alleged boundary | |violations. |

| | | |violations | | |

|4. Consumer Ratings of Trust and Clarity of Tasks and Boundaries: |No consumers rate |Fewer than 40% of |40-70% of consumers rate |71-90% of consumers rate |More than 90% of consumers|

|Consumers rate the program and its staff as trustworthy—offering clear |program trustworthiness |consumers rate program |program trustworthiness at|program trustworthiness at|rate program |

|information and maintaining appropriate professional relationships—at the |at the “agree” or higher|trustworthiness at the |the “agree” or higher |the “agree” or higher |trustworthiness at the |

|“agree” (or comparable, better than neutral) point on the rating scale or |point. |“agree” or higher point. |point. |point. |“agree” or higher point. |

|higher. | | | | | |

Domain 1C. Choice for Consumers —Maximizing Consumer Choice and Control. “To what extent do the program’s activities and settings maximize consumer experiences of choice and control?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its physical setting and its activities in order to evaluate |review has been |review has been conducted,|action plan to maximize |action plan has been |steps of the action plan |

|consumer choice and control and to make changes necessary to maximize |conducted. |including |consumer choice has been |partially implemented. |have been implemented. |

|consumer choice. | |consumer-survivor input. |developed. | | |

|2. Program Options: Staff review the program’s service options (e.g., |No consumers have |Fewer than 30% of |30-60% of consumers have |61-90% of consumers have |More than 90% of consumers|

|types of services offered, locations, housing possibilities, choices |reviewed the program’s |consumers have reviewed |reviewed the program’s |reviewed the program’s |have reviewed the |

|regarding clinicians) with each consumer prior to the development of an |service options with |the program’s service |service options with |service options with |program’s service options |

|initial recovery or service plan. |staff. |options with staff. |staff. |staff. |with staff. |

|3. Consumer Preferences: The consumer collaborates in developing a plan |No consumer plans for |Fewer than 30% of |30-60% of consumers have |61-90% of consumers have |More than 90% of consumers|

|(e.g., Wellness Recovery Action Plan and/or a crisis plan) that indicates |routine or crisis |consumers have developed |developed formal plans for|developed formal plans for|have developed formal |

|the consumer’s preferred options (including responses from staff) in both |situations have been |formal plans for both |both routine and crisis |both routine and crisis |plans for both routine and|

|routine and crisis situations. |developed. |routine and crisis |situations indicating |situations indicating |crisis situations |

| | |situations indicating |their preferences. |their preferences. |indicating their |

| | |their preferences. | | |preferences. |

|4. Consumer Ratings of Choice and Control: In program satisfaction surveys,|No consumers rate |Fewer than 40% of |40-70% of consumers rate |71-90% of consumers rate |More than 90% of consumers|

|consumers rate their experience of choice and control in the program at the |consumer choice at the |consumers rate consumer |consumer choice at the |consumer choice at the |rate consumer choice at |

|“agree” (or comparable, better than neutral) point on the rating scale or |“agree” or higher point.|choice at the “agree” or |“agree” or higher point. |“agree” or higher point. |the “agree” or higher |

|higher. | |higher point. | | |point. |

Domain 1D. Collaboration for Consumers —Maximizing Collaboration and Sharing Power: “To what extent do the program’s activities and settings maximize collaboration and sharing of power between staff and consumers?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its activities in order to assess the quality of collaboration in |review has been |review has been conducted,|action plan to maximize |action plan has been |steps of the action plan |

|staff-consumer relationships and to identify opportunities for enhancing |conducted. |including |consumer-staff |partially implemented. |have been implemented. |

|this collaboration. | |consumer-survivor input. |collaboration has been | | |

| | | |developed. | | |

|2. Consumer Input in Decision-Making: Program administrators and |No routine plan for |A plan for gathering |A plan for gathering |In addition to (3), |In addition to (4), |

|supervisors have a routine and effective way of gathering consumer opinions |gathering consumer |consumer opinions exists |consumer opinions exists |consumer opinions are |administrators and |

|about the program’s direction and operations; weigh consumers’ opinions in |opinions exists. |but is implemented |and is regularly |weighed significantly in |supervisors provide |

|their decision-making; and communicate clearly with consumers the process of| |unevenly. |implemented. |the program’s |feedback to consumers |

|decision-making. | | | |decision-making. |about decision-making. |

|3. Consumer Engagement in Recovery/Service Planning: The program creates |No consumers are |Fewer than 40% of |40-70% of consumers are |71-90% of consumers are |More than 90% of consumers|

|ways to engage consumers as partners in plans for the recovery support |routinely engaged in |consumers are engaged in |engaged in recovery |engaged in recovery |are engaged in recovery |

|services they need and want. |recovery support |recovery support planning.|support planning. |support planning. |support planning. |

| |planning. | | | | |

|4. Consumer Ratings of Collaboration: Consumers rate the program and its |No consumers rate |Fewer than 40% of |40-70% of consumers rate |71-90% of consumers rate |More than 90% of consumers|

|staff as collaborative—sharing power and respecting consumer perspectives—at|program collaboration at|consumers rate program |program collaboration at |program collaboration at |rate program collaboration|

|the “agree” (or comparable, better than neutral) point on the rating scale |the “agree” or higher |collaboration at the |the “agree” or higher |the “agree” or higher |at the “agree” or higher |

|or higher. |point. |“agree” or higher point. |point. |point. |point. |

Domain 1E. Empowerment for Consumers —Prioritizing Empowerment and Skill-Building: “To what extent do the program’s activities and settings prioritize consumer empowerment and growth?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its activities in order to assess the extent to which the program |review has been |review has been conducted,|action plan to maximize |action plan has been |steps of the action plan |

|facilitates consumer empowerment and skill-building and to identify |conducted. |including |consumer empowerment and |partially implemented. |have been implemented. |

|opportunities for enhancing this priority. | |consumer-survivor input. |skill-building has been | | |

| | | |developed. | | |

|2. Identifying Consumer Strengths: The program identifies each consumer’s |No consumer’s assessment|Fewer than 30% of |30-60% of consumers’ |61-90% of consumers’ |More than 90% of |

|strengths and resources as part of routine assessment. |has identified strengths|consumers’ assessments |assessments have |assessments have |consumers’ assessments |

| |and resources. |have identified strengths |identified strengths and |identified strengths and |have identified strengths |

| | |and resources. |resources. |resources. |and resources. |

|3. Building Consumer Skills: The program helps to develop or enhance |No formal activity |Fewer than 30% of the |30-50% of the consumer’s |51-80% of the consumer’s |More than 80% of the |

|consumer skills explicitly in each formal activity (group or individual |explicitly focuses on |consumer’s contacts |contacts explicitly focus |contacts explicitly focus |consumer’s contacts |

|contact). |consumer skill-building.|explicitly focus on |on skill-building. |on skill-building. |explicitly focus on |

| | |skill-building. | | |skill-building. |

|4. Consumer Ratings of Empowerment: Consumers rate the program and its |No consumers rate |Fewer than 40% of |40-70% of consumers rate |71-90% of consumers rate |More than 90% of consumers|

|staff as facilitating empowerment and skill-building at the “agree” (or |consumer empowerment and|consumers rate consumer |consumer empowerment and |consumer empowerment and |rate consumer empowerment |

|comparable, better than neutral) point on the rating scale or higher. |skill-building at the |empowerment and |skill-building at the |skill-building at the |and skill-building at the |

| |“agree” or higher point.|skill-building at the |“agree” or higher point. |“agree” or higher point. |“agree” or higher point. |

| | |“agree” or higher point. | | | |

Domain 1F. Safety for Staff—Ensuring Physical and Emotional Safety: “To what extent do the program’s activities and settings ensure the physical and emotional safety of staff members?”

|Criterion |1 |2 |3 |4 |5 |

|1. Physical Setting Review: The program has conducted a specific and |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|systematic review of its physical setting (including signs, waiting areas, |review has been |review has been conducted |action plan to maximize |action plan has been |steps of the action plan |

|offices, restrooms, outside spaces) in order to evaluate its physical and |conducted. |with input from all staff |staff safety has been |partially implemented. |have been implemented. |

|emotional safety and to make changes necessary to ensure staff safety. | |levels. |developed. | | |

|2. Interpersonal Contacts Review: The program has conducted a specific and|No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|systematic review of its interpersonal contacts, relationships, and |review has been |review has been conducted |action plan to maximize |action plan has been |steps of the action plan |

|activities in order to evaluate their physical and emotional safety and to |conducted. |with input from all staff |staff safety has been |partially implemented. |have been implemented. |

|make changes necessary to ensure staff safety. This review has included all| |levels. |developed. | | |

|staff (support, direct service, and administrative) and all contacts. | | | | | |

|2. Incident Review: The program systematically reviews those incidents that|No incident reviews have|A plan has been developed |In addition to (2), a plan|In addition to (3), the |In addition to (4), the |

|indicate a lack of safety (e.g., verbal and physical confrontations, |occurred. |for identifying and |has been developed for |plan has been implemented.|incident reviews are used |

|assaults) and makes changes to prevent their recurrence. | |reporting incidents that |clinical and | |to modify potentially |

| | |indicate a lack of safety |administrative review of | |unsafe practices or |

| | |(based on staff reports). |incidents that indicate a | |settings. |

| | | |lack of safety. | | |

|4. Staff Ratings of Safety: In staff surveys, staff rate program safety at|No staff members rate |Fewer than 40% of staff |40-70% of staff members |71-90% of staff members |More than 90% of staff |

|the “agree” or comparable point on the rating scale or higher. |program safety at the |members rate program |rate program safety at the|rate program safety at the|members rate program |

| |“agree” or higher point.|safety at the “agree” or |“agree” or higher point. |“agree” or higher point. |safety at the “agree” or |

| | |higher point. | | |higher point. |

Domain 1G. Trustworthiness for Staff —Maximizing Trustworthiness through Task Clarity, Consistency, and Interpersonal Boundaries: “To what extent do the program’s activities and settings maximize trustworthiness by making the tasks involved in service delivery clear, by ensuring consistent support in practice, and by maintaining boundaries that are appropriate to the program?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its physical setting and activities in order to evaluate factors |review has been |review has been conducted |action plan to maximize |action plan has been |steps of the action plan |

|related to program trustworthiness (esp. clear tasks, consistent practices, |conducted. |with input from all staff |program trustworthiness |partially implemented. |have been implemented. |

|staff-consumer, and staff-supervisor-administrator boundaries) and to make | |levels. |has been developed. | | |

|changes necessary to ensure that trustworthiness is maximized. | | | | | |

|2. Staff Support: The program supports its staff members organizationally,|No policy or plan exists|A plan has been developed |In addition to (2), the |In addition to (3), the |In addition to (4), the |

|professionally, and personally (e.g., by providing supervision that is |for providing |for providing appropriate |plan has been partially |plan has been implemented.|plan is routinely reviewed|

|attuned to the needs of both direct service and support staff; by offering |appropriate and needed |and needed support for |implemented (e.g., either | |with the staff to ensure |

|needed leave on a clear and equitable basis). Both policy and practice |support for staff |staff members. |professional or personal | |it is responsive to the |

|support staff. |members. | |support is offered but not| |staff’s current needs. |

| | | |both). | | |

|3. Review of Alleged Boundary Violations: The program has a clear procedure|No policy exists |A plan has been developed |In addition to (2), a plan|In addition to (3), the |In addition to (4), the |

|for the review of any allegations of boundary violations, including sexual |regarding review of |for identifying and |has been developed for |plan has been implemented.|incident reviews are used |

|harassment and inappropriate social contacts (including violations of |alleged boundary |reporting incidents that |clinical and | |to modify practices that |

|consumer-staff and staff-supervisor or administrator boundaries) |violations by |indicate possible boundary|administrative review of | |may lead to boundary |

| |supervisors or |violations. |alleged boundary | |violations. |

| |administrators. | |violations. | | |

|4. Staff Ratings of Trust and Clarity of Tasks and Boundaries: Staff rate|No staff members rate |Fewer than 40% of staff |40-70% of staff members |71-90% of staff members |More than 90% of staff |

|the program and its supervisors and administrators as trustworthy—offering |program trustworthiness |members rate program |rate program |rate program |members rate program |

|clear expectations and appropriate professional supports—at the “agree” (or |at the “agree” or higher|trustworthiness at the |trustworthiness at the |trustworthiness at the |trustworthiness at the |

|comparable, better than neutral) point on the rating scale or higher. |point. |“agree” or higher point. |“agree” or higher point. |“agree” or higher point. |“agree” or higher point. |

Domain 1H. Choice for Staff —Maximizing Staff Choice and Control. “To what extent do the program’s activities and settings maximize staff members’ experiences of choice and control?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its physical setting and its activities in order to evaluate staff|review has been |review has been conducted,|action plan to maximize |action plan has been |steps of the action plan |

|choice and control and to make changes necessary to maximize staff members’ |conducted. |including input from all |staff choice has been |partially implemented. |have been implemented. |

|choice. | |staff levels. |developed. | | |

|2. Program Options: Supervisors or administrators review the program’s |Staff options have been |Fewer than 30% of staff |30-60% of staff members |61-90% of staff members |More than 90% of staff |

|options (e.g., staff’s employment goals, hours and flex-time, timing of |reviewed with no staff |members have reviewed the |have reviewed the |have reviewed the |members have reviewed the |

|vacation, kinds of training offered, service approaches, location and décor |members. |program’s service options |program’s service options |program’s service options |program’s service options |

|of office space) with each staff member as part of the initial hiring or | |with supervisors or |with supervisors or |with supervisors or |with supervisors or |

|review process. | |administrators. |administrators. |administrators. |administrators. |

|3. Staff Ratings of Choice and Control: In program satisfaction surveys, |No staff members rate |Fewer than 30% of staff |30-60% of staff members |61-90% of staff members |More than 90% of staff |

|staff members rate their experience of choice and control in the program at |staff choice at the |members rate staff choice |rate staff choice at the |rate staff choice at the |members rate staff choice |

|the “agree” (or comparable, better than neutral) point on the rating scale |“agree” or higher point.|at the “agree” or higher |“agree” or higher point. |“agree” or higher point. |at the “agree” or higher |

|or higher. | |point. | | |point. |

Domain 1I. Collaboration—Maximizing Collaboration and Sharing Power: “To what extent do the program’s activities and settings maximize collaboration and sharing of power between staff and consumers?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its activities in order to assess the quality of collaboration in |review has been |review has been conducted |action plan to maximize |action plan has been |steps of the action plan |

|staff-supervisor and administrator relationships and to identify |conducted. |with input from all staff |staff-supervisor-administr|partially implemented. |have been implemented. |

|opportunities for enhancing this collaboration. | |levels. |ator collaboration has | | |

| | | |been developed. | | |

|2. Staff Input in Decision-Making: Program administrators and supervisors |No routine plan for |A plan for gathering staff|A plan for gathering staff|In addition to (3), staff |In addition to (4), |

|have a routine and effective way of gathering staff opinions about the |gathering staff opinions|opinions exists but is |opinions exists and is |opinions are weighed |administrators and |

|program’s direction and operations; weigh staff opinions in their |exists. |implemented unevenly. |regularly implemented. |significantly in the |supervisors provide |

|decision-making; and communicate clearly with staff the process of | | | |program’s decision-making.|feedback to the staff |

|decision-making. | | | | |about decision-making. |

|3. Staff Ratings of Collaboration: Staff members rate the program and its |No staff members rate |Fewer than 40% of staff |40-70% of staff members |71-90% of staff members |More than 90% of staff |

|supervisors and administrators as collaborative—sharing power and respecting|program collaboration at|members rate program |rate program collaboration|rate program collaboration|members rate program |

|staff perspectives—at the “agree” (or comparable, better than neutral) point|the “agree” or higher |collaboration at the |at the “agree” or higher |at the “agree” or higher |collaboration at the |

|on the rating scale or higher. |point. |“agree” or higher point. |point. |point. |“agree” or higher point. |

Domain 1J. Empowerment for Staff —Prioritizing Empowerment and Skill-Building: “To what extent do the program’s activities and settings prioritize staff empowerment and growth?”

|Criterion |1 |2 |3 |4 |5 |

|1. Program Review: The program has conducted a specific and systematic |No specific, systematic |A systematic program-wide |In addition to (2), an |In addition to (3), the |In addition to (4), all |

|review of its activities in order to assess the extent to which the program |review has been |review has been conducted |action plan to maximize |action plan has been |steps of the action plan |

|facilitates staff empowerment and skill-building and to identify |conducted. |with input from all staff |staff empowerment and |partially implemented. |have been implemented. |

|opportunities for enhancing this priority. | |levels. |skill-building has been | | |

| | | |developed. | | |

|2. Identifying Staff Strengths: The program identifies each staff member’s|No staff member’s |Fewer than 30% of staff |30-60% of staff members |61-90% of staff members |More than 90% of staff |

|strengths and resources as part of routine supervision and review. |supervisor has |members have had their |have had their strengths |have had their strengths |members have had their |

| |identified strengths and|strengths and resources |and resources identified |and resources identified |strengths and resources |

| |resources. |identified by supervisors.|by supervisors. |by supervisors. |identified by supervisors.|

|3. Providing Necessary Resources: The program provides needed resources |No plan to identify and |A preliminary plan to |In addition to (2), the |In addition to (3), all |In addition to (4), the |

|for staff to meet their job requirements (e.g., by offering help with |provide needed resources|offer necessary resources |plan has been partially |steps of the plan have |review of resources is |

|transportation of consumers; providing needed supplies and electronic |has been developed. |has been developed. |implemented. |been implemented. |part of ongoing |

|support; offering necessary backup staff). | | | | |administrative tasks. |

|4. Staff Ratings of Empowerment: Staff members rate the program and its |No staff members rate |Fewer than 40% of staff |40-70% of staff members |71-90% of staff members |More than 90% of staff |

|staff as facilitating empowerment and skill-building at the “agree” (or |staff empowerment and |members rate staff |rate staff empowerment and|rate staff empowerment and|members rate staff |

|comparable, better than neutral) point on the rating scale or higher. |skill-building at the |empowerment and |skill-building at the |skill-building at the |empowerment and |

| |“agree” or higher point.|skill-building at the |“agree” or higher point. |“agree” or higher point. |skill-building at the |

| | |“agree” or higher point. | | |“agree” or higher point. |

Domain 2. Formal Service Policies: “To what extent do the formal policies and procedures of the program reflect an understanding of trauma and recovery?”

|Criterion |1 |2 |3 |4 |5 |

|1. Eliminating Involuntary Treatment: The program has developed written |No relevant policies |Policies designed to |In addition to (2), |In addition to (3), |In addition to (4), |

|policies that seek to eliminate involuntary or coercive practices (seclusion|have been developed. |eliminate involuntary |policies are consistently |instances of involuntary |survivor-consumers are |

|and restraint, involuntary hospitalization or medication, outpatient | |treatment have been |implemented. |treatment are regularly |routinely involved in this|

|commitment). | |developed. | |reviewed in order to |review of both policy and |

| | | | |improve practice. |practice. |

|2. Consumer Crisis Preferences (A): The program has a written policy and |No policy or procedure |A relevant policy, |In addition to (2), this |In addition to (3), |In addition to (4), crisis|

|formal procedure for inquiring about and respecting consumer preferences for|has been developed. |specifying a procedure |procedure includes steps |instances of crisis |response procedures are |

|responding in crisis situations. | |(e.g., a standard form) |to ensure the staff’s |response are regularly |adjusted as necessary to |

| | |for inquiring about |awareness of and attention|reviewed in order to |maximize attention to |

| | |consumer crisis |to these preferences. |ensure consideration of |consumer preferences. |

| | |preferences, has been | |consumer preferences. | |

| | |developed. | | | |

|3. Consumer Crisis Preferences (B): Each consumer has been asked about |No consumer is asked |Fewer than 30% of |30-60% of consumers are |61-90% of consumers are |More than 90% of consumers|

|crisis preferences and their responses are available to all appropriate |about crisis |consumers are asked OR |asked OR 30-60% of |asked OR 61-90% of |are asked AND more than |

|direct service staff. |preferences. |their preferences are not |consumer preferences are |consumer preferences are |90% of consumer |

| | |known by all relevant |known by all relevant |known by all relevant |preferences are known by |

| | |staff. |staff. |staff. |all relevant staff. |

|4. De-escalation Policy: The program has a written de-escalation policy |No written de-escalation|The program has a written |In addition to (2), this |In addition to (3), |In addition to (4), the |

|that minimizes possibility of retraumatization; the policy includes |policy exists. |de-escalation policy that |policy is regularly |de-escalation situations |de-escalation policy is |

|reference to a consumer’s statement of preference for crisis response. | |minimizes retraumatization|implemented. |are regularly reviewed in |adjusted as necessary to |

| | |and includes consumer | |order to ensure attention |maximize attention to |

| | |crisis preferences. | |to consumer preferences. |consumer preferences. |

|Criterion |1 |2 |3 |4 |5 |

|5. Confidentiality (A): Policies regarding confidentiality (including |No written |A written confidentiality |In addition to (2), the |In addition to (3), |In addition to (4), |

|limits) and access to information are clearly written and maximize legal |confidentiality policy |policy exists and is |policy maximizes the legal|instances that reflect |confidentiality policy is |

|protection of consumer privacy. |exists OR it is written |clearly written. |protection of consumer |limits of confidentiality |adjusted to maximize |

| |in a way difficult for | |privacy. |are routinely reviewed. |clarity and consumers’ |

| |consumers to understand.| | | |privacy within legal |

| | | | | |limits. |

|6. Confidentiality (B): Program confidentiality policies, including limits|No consumer has been |Fewer than 30% |30-60% of consumers have |61-90% of consumers have |More than 90% of consumers|

|of confidentiality, are communicated to each consumer. |given information about |of consumers have been |been given information |been given information |have been given |

| |confidentiality and its |given information about |about confidentiality and |about confidentiality and |information about |

| |limits. |confidentiality and its |its limits. |its limits. |confidentiality and its |

| | |limits. | | |limits. |

|7. Consumer Rights and Responsibilities (A): The program has a clearly |No written consumer |A written statement of |In addition to (2), the |In addition to (3), the |In addition to (4), |

|written and easily accessible policy outlining consumer rights and |rights and |consumer rights and |statement is readily |statement is reviewed for |consumer-survivors are |

|responsibilities. |responsibilities policy |responsibilities exists |available for consumers. |possible revision on at |involved in the writing of|

| |exists OR it is written |and is clearly written. | |least an annual basis. |the statement. |

| |in a way difficult for | | | | |

| |consumers to understand.| | | | |

|8. Consumer Rights and Responsibilities (B): The program’s policy |No consumer has been |Fewer than 30% of |30-60% of consumers have |61-90% of consumers have |More than 90% of consumers|

|regarding consumer rights and responsibilities has been communicated to each|given the statement of |consumers have been given |been given the statement. |been given the statement. |have been given the |

|consumer. |rights and |the statement. | | |statement AND the |

| |responsibilities. | | | |statement is posted |

| | | | | |publicly. |

Domain 3. Trauma Screening, Assessment, and Service Planning: “To what extent does the program have a consistent way to identify individuals who have been exposed to trauma and to include trauma-related information in planning services with the consumer?”

|Criterion |1 |2 |3 |4 |5 |

|1. Universal Trauma Screening: Within the first month of service |No consumer has been |Fewer than 30% of |30-60% of consumers have |61-90% of consumers have |More than 90% of consumers|

|participation, every consumer has been asked about exposure to trauma. |asked about trauma |consumers have been asked,|been asked about trauma |been asked about trauma |have been asked about |

| |exposure. |within the first month of |exposure. |exposure. |trauma exposure. |

| | |service participation, | | | |

| | |about trauma exposure. | | | |

|2. Trauma Screening Content: The trauma screening includes questions about|No standardized trauma |A standardized screening |A standardized screening |The screening includes |The standardized screening|

|lifetime exposure to sexual and physical abuse. |screening approach |for trauma has been |approach has been |questions about EITHER |includes questions about |

| |exists. |approved but not |implemented but does not |sexual OR physical abuse |lifetime exposure to both |

| | |implemented. |include questions about |OR about abuse in general |physical and sexual abuse |

| | | |sexual or physical abuse. |OR about a specific time | |

| | | | |period. | |

|3. Trauma Screening Process: The trauma screening is implemented in ways |No discussion of the |A plan for minimizing |A screening plan that |The screening process is |Consumers and staff report|

|that minimize consumer stress; it reflects considerations given to timing, |screening process has |stress in screening has |includes flexible |routinely reviewed to |satisfaction with the |

|setting, relationship to interviewer, consumer choice about answering, and |occurred. |been developed. |responses to consumers has|ensure that it minimizes |screening process. |

|unnecessary repetition. | | |been implemented. |consumer and staff | |

| | | | |distress. | |

|Criterion |1 |2 |3 |4 |5 |

|4. Trauma Assessment: Unless specifically contraindicated due to consumer |The program has |A plan for conducting |An assessment plan that |The assessment process is |Consumers and staff report|

|distress, the program conducts a more extensive assessment of trauma history|conducted no trauma |trauma assessments has |includes both trauma |routinely reviewed to |satisfaction with the |

|and needs and preferences for trauma-specific services for those consumers |assessments. |been developed. |history and service needs |ensure that it minimizes |assessment process. |

|who report trauma exposure. | | |and preferences has been |consumer and staff | |

| | | |implemented. |distress. | |

|5. Trauma and Service Planning: The program ensures that those individuals|No referrals for |A plan for referrals, |In addition to (2), fewer |In addition to (2), 30-80%|In addition to (2), more |

|who report the need and/or desire for trauma-specific services are referred |trauma-specific services|incl. the accessibility of|than 30% of those needing |of those needing or |than 80% of those needing |

|for appropriately matched services. |are made. |trauma-specific services, |or requesting |requesting trauma-specific|or requesting |

| | |has been developed. |trauma-specific services |services are referred for |trauma-specific services |

| | | |are referred for |accessible services. |are referred for |

| | | |accessible services. | |accessible services. |

|6. Trauma-Specific Services: The program offers, or has identified other |No trauma-specific |Offered or identified |Offered or identified |Offered or identified |Offered or identified |

|programs that offer, trauma-specific services with four “criterion” |services are offered or |trauma-specific services |trauma-specific services |trauma-specific services |trauma-specific services |

|characteristics: effective, accessible, affordable, and responsive to the |identified. |have one of the four |have two of the four |have three of the four |have all four of the |

|preferences of the program’s consumers. | |criterion characteristics.|criterion characteristics.|criterion characteristics.|criterion characteristics.|

Domain 4. Administrative Support for Program-Wide Trauma-Informed Services: “To what extent do agency administrators support the integration of knowledge about trauma and recovery into all program practices?”

|Criterion |1 |2 |3 |4 |5 |

|1. Written Policy Statement: The program has adopted a formal policy |No senior level |Senior level |In addition to (2), |In addition to (3), |In addition to (4), |

|statement that refers to the importance of trauma and the need to account |discussion has occurred.|administrators have |administrators have |administrators have |statement is prominently |

|for consumer experiences of trauma in all aspects of program operation. | |participated in discussion|reviewed draft statement. |approved adoption of |displayed in program |

| | |of statement. | |statement. |description. |

|2. Support for Trauma-Informed Leadership: The program has named a trauma |No trauma specialist or |Specialist or workgroup |In addition to (2), |In addition to (3), action|In addition to (4), |

|specialist or workgroup(s) to lead agency activities in trauma-related areas|workgroup has been |has been identified and |resources (staff time, |plan has been adopted and |initial action plan has |

|and provides needed support for trauma initiatives. |identified. |given a clear mission. |budget) have been |initial steps taken. |been substantially |

| | | |allocated. | |completed. |

|3. Administrative Participation in and Oversight of Trauma-Informed |No reporting or |Administrators are |In addition to (2), |In addition to (3), |In addition to (4), |

|Approaches: Program administrators monitor and participate actively in |monitoring of |informed of trauma |administrators meet |administrators routinely |administrators include |

|responding to the recommendations and activities of the trauma leadership. |trauma-related |specialist or workgroup |periodically with trauma |monitor implementation of |trauma initiatives in |

| |activities occurs. |activities. |specialist or workgroup. |trauma activities. |formal reports and |

| | | | | |publications. |

|4. Trauma Survivor-Consumer Involvement (A): Administrators work with a |No Consumer Advisory |Consumer Advisory Board |Consumer Advisory Board |Consumer Advisory Board |In addition to (4), |

|Consumer Advisory Board (CAB) that includes consumers who have had lived |Board exists. |exists but has no |has one member who |has at least two members |administrators ensure that|

|experiences of trauma. | |self-identified trauma |self-identifies as a |who self-identify as |trauma initiatives are |

| | |survivor-consumers. |survivor-consumer. |survivor-consumers. |addressed in meetings with|

| | | | | |the CAB. |

|5. Trauma Survivor-Consumer Involvement (B): |No survivor-consumers |Survivor-consumer |In addition to (2), this |In addition to (3), |In addition to (4), |

|Consumers who have had lived experiences of trauma are actively involved in |are involved in program |workgroup has been formed.|workgroup makes |survivor-consumers are |survivor-consumers have |

|all aspects of program planning and oversight. |or agency planning. | |recommendations to |represented on major |paid positions in the |

| | | |administrators regarding |agency standing |agency; positions draw |

| | | |trauma initiatives. |committees. |explicitly on lived |

| | | | | |experience. |

|Criterion |1 |2 |3 |4 |5 |

|6. Needs Assessment and Program Evaluation: Program gathers data addressing|No data are gathered. |The program has gathered |In addition to (2), the |In addition to (3), the |In addition to (4), the |

|the needs and strengths of consumers who are trauma survivors and evaluates | |data regarding prevalence |program has developed a |program regularly monitors|program incorporates |

|the effectiveness of the program and trauma-specific services. | |of trauma and needs of |plan to monitor the |process and outcomes. |program evaluation results|

| | |survivors. |process (incl. consumer | |in its planning for |

| | | |satisfaction) and outcomes| |trauma-related services. |

| | | |of trauma services. | | |

|7. Trauma and Consumer Satisfaction: Administrators include at least five |None of the five areas |One of the areas is |Two or three of the areas |Four of the areas are |All five of the areas are |

|key principles of trauma-informed services in consumer satisfaction surveys:|is included in surveys |included in surveys. |are included in surveys. |included in surveys. |included in surveys. |

|safety, trustworthiness, choice, collaboration, and empowerment (see Domain |(or surveys are not | | | | |

|1). |standardized). | | | | |

Domain 5. Staff Trauma Training and Education: “To what extent have all staff members received appropriate training in trauma and its implications for their work?”

|Criterion |1 |2 |3 |4 |5 |

|1. General Trauma Education for All Staff (A): All staff (including |No trauma education |Fewer than 30% of staff |30-60% of staff have |61-90% of staff have |More than 90% of staff |

|administrative and support personnel) have participated in at least three |designed for all staff |have participated in basic|participated in basic |participated in basic |have participated in basic|

|hours of “basic” trauma education that addresses at least the following: a) |has been offered. |trauma education OR more |trauma education OR more |trauma education OR more |trauma education that |

|trauma prevalence, impact, and recovery; b) ensuring safety and avoiding | |than 50% of staff have |than 50% of staff have |than 50% of staff have |includes all six content |

|retraumatization; c) maximizing trustworthiness (clear tasks and | |received trauma education |received trauma education |received trauma education |areas. |

|boundaries); d) enhancing consumer choice; e) maximizing collaboration; and | |that includes only one of |that includes two or three|that includes four or five| |

|f) emphasizing empowerment. | |the content areas. |of the content areas. |of the content areas. | |

|2. General Trauma Education for All Staff (B): All new staff receive at |No new staff have |Fewer than 30% of staff |30-60% of staff have |61-90% of staff have |More than 90% of staff |

|least one hour of trauma education as part of orientation. |received trauma |have received trauma |received trauma education |received trauma education |have received trauma |

| |education in |education in orientation. |in orientation. |in orientation. |education in orientation. |

| |orientation. | | | | |

|3. Education for Direct Services Staff (A): Direct service staff have |No direct services staff|Fewer than 30% of direct |30-60% of direct services |61-90% of direct services |More than 90% of staff |

|received at least three hours of education involving trauma-informed |have received this |services staff have |staff have received this |staff have received this |have received this |

|modifications in their content areas (e.g., care coordination, housing, |education. |received this education. |education. |education. |education. |

|substance use). | | | | | |

|4. Education for Direct Services Staff (B): Direct service staff have |No direct services staff|Fewer than 30% of these |30-60% of direct services |61-90% of direct services |More than 90% of staff |

|received at least three hours of education involving trauma-specific |have received this |staff have received this |staff have received this |staff have received this |have received this |

|techniques (e.g., grounding, teaching trauma recovery skills). |education. |education. |education. |education. |education. |

|5. Support for Direct Services Staff : Direct service staff offering |No specific support for |Administrators have |General support is offered|Trauma-focused support is |Staff report that |

|trauma-specific services are provided adequate resources for self-care, |direct services staff is|developed a plan for |but does not address |offered and made |trauma-focused support is |

|including supervision, consultation, and/or peer support that addresses |offered. |offering support. |secondary traumatization. |accessible for staff. |adequate to meet their |

|secondary traumatization. | | | | |needs. |

Domain 6. Human Resources Practices: “To what extent are trauma-related considerations part of the hiring and performance review process?”

|Criterion |1 |2 |3 |4 |5 |

|1. Prospective Staff Interviews: Interviews include trauma-related |Interviews do not |Fewer than 30% of |30-60% of interviews |61-90% of interviews |More than 90% of |

|questions. (What do applicants know about trauma, including sexual and |address trauma. |interviews address trauma.|address trauma. |address trauma. |interviews address trauma.|

|physical abuse? About its impact? About recovery and healing? Is there a | | | | | |

|“blaming the victim” bias? Is there potential to be a trauma “champion?”) | | | | | |

|2. Staff Performance Reviews: Staff performance reviews include |Performance reviews do |Fewer than 30% of |30-60% of performance |61-90% of performance |More than 90% of |

|trauma-informed skills and tasks, including the development of safe, |not address |performance reviews |reviews address |reviews address |performance reviews |

|trustworthy, collaborative, and empowering relationships with consumers that|trauma-informed skills. |address trauma-informed |trauma-informed skills. |trauma-informed skills. |address trauma-informed |

|maximize consumer choice. | |skills. | | |skills. |

|3. Staff Knowledge Assessment: The program routinely assesses staff |No assessment of staff |Fewer than 30% of staff |30-60% of staff members’ |61-90% of staff members’ |More than 90% of staff |

|members’ knowledge of trauma (see content in Domain 5). This may be done |members’ trauma-related |members’ trauma knowledge |trauma knowledge is |trauma knowledge is |members’ trauma knowledge |

|following educational events or as part of performance reviews or in ongoing|knowledge is conducted. |is assessed. |assessed. |assessed. |is assessed. |

|supervision. | | | | | |

Agency/Program ________________________________________ Date ___________

Person(s) Completing Scale:_______________________________________________

Domain 1. Program Procedures and Settings

1A 1. _____ 1C 1. _____ 1E 1. _____ 1G 1. _____ 1I 2. ______

1A 2. _____ 1C 2. _____ 1E 2. _____ 1G 2. _____ 1I 3. ______

1A 3. _____ 1C 3. _____ 1E 3. _____ 1G 3. _____ 1J 1. ______

1A 4. _____ 1C 4. _____ 1E 4. _____ 1G 4. _____ 1J 2. ______

1B 1. _____ 1D 1. _____ 1F 1. _____ 1H 1. _____ 1J 3. ______

1B 2. _____ 1D 2. _____ 1F 2. _____ 1H 2. _____ 1J 4. ______

1B 3. _____ 1D 3. _____ 1F 3. _____ 1H 3. _____

1B 4. _____ 1D 4. _____ 1F 4. _____ 1I 1. _____ Domain 1 Subtotal ____________

Domain 2. Formal Services Policies

1. ___________ 5. ___________

2. ___________ 6. ___________

3. ___________ 7. ___________

4. ___________ 8. ___________ Domain 2 Subtotal ___________

Domain 3: Trauma Screening, Assessment, and Service Planning

1. ___________ 4. ___________

2. ___________ 5. ___________

3. ___________ 6. ___________ Domain 3 Subtotal ___________

Domain 4: Administrative Support for Program-Wide Trauma-Informed Services

1. ___________ 5. ___________

2. ___________ 6. ___________

3. ___________ 7. ___________

4. ___________ Domain 4 Subtotal ___________

Domain 5: Staff Trauma Training and Education

1. ___________ 4. ___________

2. ___________ 5. ___________

3. ___________ Domain 5 Subtotal ___________

Domain 6: Human Resources Practices

1. ___________ 3. ___________

2. ___________ Domain 6 Subtotal ___________

Grand Total ________________÷ 67 = Overall Mean of ___________________________

Interpretive ranges for overall mean: 1.00-2.00 = Beginning the trauma-informed process

2.00-3.00 = Not very trauma-informed

3.00-4.00 = Somewhat trauma-informed

4.00-5.00 = Very trauma-informed

5.00 = Fully trauma-informed

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