DHHS91073 Form 5 - Attestation-Evidence-Based Program Models for Prevention of Foster Care Services.pdf

DHHS91073 - Form 5

ATTESTATION – EVIDENCE-BASED PROGRAM MODELS FOR PREVENTION OF

FOSTER CARE SERVICES

INSTRUCTIONS: Please check the box next to the attestation statement under each evidence-based program model you are applying for. Please do not check the box if you are not applying for that evidence-based program model.

Parent-Child Interaction Therapy (“PCIT”):

� I attest that each qualified mental health professional that will provide PCIT for me is currently certified in PCIT from PCIT International; OR is currently participating in training and supervision in PCIT from a PCIT International Certified Trainer, and is making appropriate progress toward certification.

Trauma Focused Cognitive Behavioral Therapy (“TF-CBT”):

� I attest that each qualified mental health professional that will provide TF-CBT for me is currently certified in TF-CBT from the TF-CBT National Therapist Certification Program; OR is currently participating in training and supervision in TF-CBT from a TF-CBT National Therapist Certified Trainer, and is making appropriate progress toward certification; OR received formal training in TF-CBT prior to 2013.

I agree that each qualified mental health professional that will provide TF-CBT for me will record every TF-CBT designated session and utilize the TF-CBT Brief Practice Checklist for each session.

Functional Family Therapy (“FFT”):

� I attest that I have a current FFT site certification and am currently participating in ongoing site certification training OR am currently working toward attaining FFT site certification, and am making appropriate progress toward certification.

Motivational Interviewing (“MI”):

� I attest that each qualified mental health professional that will provide MI for me has received training in MI from a certified trainer; OR is currently participating in training and supervision in MI from a certified trainer, and is making appropriate progress toward certification.

I agree that each qualified mental health professional that will provide MI for me will record every MI designated session.

* Please note: Prior to providing services, you will be required to provide DHHS with information pertaining to the mental health professional(s) providing services for you, including the name(s) of the qualified mental health professional(s) and status of training or certification.

By signing this document I certify that the information I have given is true and complete to the best of my knowledge.

Signature of Vendor’s Authorized Representative Print Vendor Business Name

Print Name and Title of Authorized Representative Date