STAR program operations guide - ACH Child and Family Services

STAR program operations guide - ACH Child and Family Services
Program Operations Guide
Services To At-Risk
Youth Program
STAR
Texas Department of Family and Protective Services
Division of Prevention and Early Intervention
September 1, 2012
Table of Contents
1.
Program Information ....................................................................... 1
2.
Family and Youth Short-term Counseling ……………….……………………………….. 2
3.
Family and Youth Skills Group .…...…………….…………………………….………………4
4.
Crisis Counseling ………………………………………………………………………………………….6
5.
Emergency Care Services (Youth Shelter Services) ………………………………….7
6.
Universal Child Abuse Prevention (UCAP) and Street Outreach Services ….9
7.
Eligibility Criteria ……………………………………………………………………………………….11
8.
Registration Form 2075A ………………………………………………………………………….14
1) Client Information - Social Security Number ..………………………………….14
2) Other Family Members ………………………………………………………………………14
3) Follow-up Due Date ………………………………………………………………………….15
9.
STAR Database Access - Log-In/Passwords.…………………………………………….17
10. Service Unit Documentation ………………………………………………………………………20
11. Request to unfreeze a closed month ………………………………………………………..22
12. Technical Assistance Request (TAR) Form ……………………………………………….24
13. STAR Action Plans ………………………………………………………………………………………26
14. STAR Performance Measures and Reporting …………………………………………….28
15. STAR Payment Methodology ……………………………………………………………………..31
16. Service Time Limits ……………………………………………………………………………………33
17. Telemedicine ………………………………………………………………………………………………35
Attachment
Attachment
Attachment
Attachment
Attachment
Attachment
A - Form 2075A …………………………………………………………………………………..37
B - Action Plan for FY 2013 …………………………………………………………………42
C - FY 2013 Performance Measures (Outputs & Outcomes) …………….43
D - Quarterly Ongoing Monitoring and Database Reports Form ……….47
E - Quarterly Corrective Action Plan Form …………………………………………48
F - PCG Pre/Post - Protective Factors Survey ……………………………………51
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Program Information
STAR.1
September 1, 2012
STAR Request for Proposal
Policy
The Services to At-Risk Youth (STAR) program is a prevention and early
intervention program administered by the DFPS Prevention and Early
Intervention Division, based on the availability of funds as appropriated by
the Texas Legislature. The program targets youth (ages 0-17) and their
families, and is designed to reduce child maltreatment and juvenile
delinquency, and increase families' protective factors and resiliency to crisis.
(see "Eligibility Criteria" for more information on who is eligible for STAR
services)
Services are short-term, lasting no more than 180 days during a rolling 12month period. A "rolling 12-month period" includes the 12-months
immediately preceding the current date of service. The STAR Program
contains specific service components, and the contractor will be required to
make available, and provide as needed, any combination of services and/or
appropriate order in which a family or youth can access the services.
STAR Services: The STAR program provides crisis counseling and support
services, such as:
•
Individual and family short-term counseling
•
Youth Skills groups
•
Family Skills groups (parenting classes)
•
Emergency care services (short-term emergency residential care)
•
Universal child abuse prevention (UCAP) services including outreach and
awareness
•
Street outreach service and referral/resource services
See individual policies located within this program manual for descriptions
about each service. In addition, each STAR contractor may offer additional
services that support the primary goals and services of the program.
1
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Family and Youth Short-Term Counseling
STAR.2
September 1, 2012
STAR Request for Proposal
Policy
Family and Youth Short-term counseling must be designed to reduce conflict,
stress, and tension among the family members so the youth can remain in or
be returned to his or her home. In addition, counseling sessions should
provide guidance to families and youth to:
•
•
Avert crisis and build resiliency in the family and youth; and,
Prevent or reduce child abuse and neglect and/or juvenile delinquency.
Counseling services must be offered within one (1) week of the initial
referral. If a family cannot be seen within the stated time period, the
contractor must make the appropriate referrals for the family and youth to
other community resources.
For all presenting problems, the primary caregiver and the youth are
required to participate in family counseling services and the remainder of
the family should be encouraged to participate as well.
Family and youth counseling sessions are preferred to be face-to-face;
however, phone or online counseling may be provided if face-to-face
interaction is not feasible. The expectation is phone and online counseling
sessions will be conducted in emergency situations and limited in usage.
Note: Only face-to-face sessions can be billed under the feefor- service rate structure. The face-to-face portion of the
session must be at least 35 consecutive minutes. Clients must
participate in more than one counseling session, with an
expected average of three (3) hours of counseling per client. Clients
with less than three hours should have the justification sufficiently
documented in their file.
STAR clients may be self-referred or referred by other sources such as: other
social service agencies, county judges, school administrators/counselors,
juvenile court, and other family members. Contractors are required to:
1. Maintain a file with client data gathered at intake and assessment; and,
2. Register the participants in the STAR database.
2
FAQs
1. What if a family refuses to participate in family counseling
services?
Participation of the primary caregiver and youth in family counseling is a
requirement.
2. Do contractors enter telephone counseling sessions that occur
over the phone in the database?
Yes; however, only face-to-face sessions are billable.
3
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Family and Youth Skills Groups
STAR.3
September 1, 2012
STAR Request for Proposal
Policy
Family skills groups and youth coping skills training groups must be provided
to STAR clients. Family skills groups are curriculum-based, parenting skills
classes provided to parents that are designed to prevent future disruptions,
improve family functioning, and build resiliency and avert crisis. Youth skills
groups is also curriculum-based training designed to prevent future
disruptions, build resiliency and avert crisis, but they are provided to the
youth and should also improve the youth's coping skills. Both sets of classes
should focus on addressing, at a minimum, the following:
•
•
•
•
•
Communication
Problem-solving
Decision-making
Anger management
Conflict resolution
Procedures
Contractors should encourage primary caregivers and youth participating in
STAR services to attend skills training groups, as appropriate. STAR clients
that are registered and attending the skills groups must sign in on some sort
of log or list when attending any group meeting. These sign-in sheets must
be maintained by the contractor and documentation of attendance of a skills
group should be maintained in the client file. The contractor must also enter
the attendance of these groups into the database.
Clients must participate in more than one group session,
with an expected average of three (3) group sessions
per client. Clients with less than three group sessions
should have the justification sufficiently documented in
their file.
4
FAQs
1. Is participation in a skills group session mandatory for all
clients?
Skills group is considered a core service so contractors should encourage
primary caregivers and youth to participate; however, the client may still
choose to only participate in family counseling and opt not to participate in a
skills group.
2. My staff forgot to have them sign a sign-in sheet at last night's
group. Can I still enter the services in the database?
No. You must have proof that the client attended the group and the sign-in
sheet is the proof attendance and would be requested at monitoring. You
should only bill PEI and enter services in the database for those services
which you have supporting documentation.
5
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Crisis Counseling
STAR.4
September 1, 2012
STAR Request for Proposal
Policy
Crisis counseling for families and youth must be available 7 days a week, 24
hours a day, 365 days a year, including weekends and holidays. Crisis
intervention must include immediate access to a crisis intervention counselor
or trained responder via phone. Additionally, clients are to have a face-toface session as soon as possible, but at least within 24 hours of the crisis
referral. Crisis intervention services must include a toll-free telephone
service and emergency care, if appropriate.
Services must be available in all proposed counties, regardless of whether
they are provided in an office, in the client's home or in another community
location. Service documentation of the service(s) provided will be required,
both in the case file, if one is created, and the STAR database.
Contractors must conduct a quick and thorough assessment to determine the
level of crisis and to identify immediate needs of the family and youth, such
as emergency care services, suicide prevention, domestic violence, and other
services that may fall outside of STAR services.
Procedures
Immediate crisis counseling services must include a crisis resolution
component. Furthermore, an effective crisis resolution process should
contain the following critical elements:
•
•
•
•
•
•
•
Assessment of the crisis
Establishment of rapport
Identification of the major problem(s)
Addressing emotions and feelings
Exploration of alternatives
Implementation of steps to resolve the crisis
Follow-up with participants
After the immediate crisis is allayed, the formal intake process must take
place within 48 hours of the crisis referral if the contractor decides to initiate
going services.
6
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Emergency Care Services (Youth Shelter
Services
STAR.5
September 1, 2012
STAR Request for Proposal
Policy
Emergency Care Services must be available 7 days a week, 24 hours a day,
365 days a year, including holidays. Emergency services are short-term, and
the use of the emergency shelter for the STAR program is limited to "Youth
aged 10 - 17" years of age.
Emergency care services may be provided by emergency shelters, foster
homes, or other short-term care facilities. All facilities that are used to
provide short-term shelter care must be licensed by the Child Care Licensing
Division of DFPS. The list of DFPS licensed facilities can be found at:
http://www.dfps.state.tx.us/child_care/search_Texas_Child_Care/
Contractors may subcontract with a licensed facility to provide emergency
care services for youth. In addition, contractors must develop and
implement a backup plan in the event the emergency care shelter cannot
accept a youth due to licensing constraints, or capacity issues.
Procedures
Contractors who place or assist in the placement of a youth in emergency
care services are required to do the following:
•
•
•
•
•
Emergency shelter placement without parental or conservator consent
must, within 24 hours, include a diligent search by the contractor to
locate parents or conservators.
Placement must always be preceded by an intake and brief assessment by
the STAR on-call counselor to ensure the placement is appropriate and all
applicable laws regarding contact with parent/guardians have been
followed.
Prior to placement in an emergency shelter, every effort should be made
to preserve the youth in the family home. Placement in the emergency
shelter should be the last resort and be clearly discussed in the progress
notes.
Contractor must arrange face-to-face contact with the youth within 24
hours if emergency care is a subcontracted service.
Contractor will be responsible for developing a STAR Action Plan.
7
•
•
•
•
The youth must be seen at least three (3) times weekly while in the
shelter, with coordinated services provided by the primary contractor and
subcontracted facility staff.
Family counseling sessions must occur between the youth and
parent/guardian while the youth is in the shelter.
Contractor must develop a plan for the re-unification of the family.
All services must be documented and maintained in the youth's case file.
8
Policy Title
Universal Child Abuse Prevention (UCAP) and
Street Outreach Services
Policy Number
Effective/Revision Date
Authority/Reference(s)
STAR.6
September 1, 2012
STAR Request for Proposal
Policy
Universal Child Abuse Prevention (UCAP) and Street Outreach Services are
intended to promote awareness of STAR services and provide child abuse and
neglect prevention information to the community at large. UCAP and Street
Outreach Services must be provided by all STAR contractors. UCAP services
are designed to increase the knowledge and awareness of child maltreatment
and promote healthy parenting and family interaction. The services are
voluntary and are available to families in the community at large, regardless
of risk. Street Outreach Services are directed to youth who are homeless,
disenfranchised, unsupervised, or at risk of involvement with negative peer
groups/gangs, particularly in major urban areas. Note that if data reflect a
low incidence of homelessness or street youth in a county, contractors may
conduct ongoing community assessments to determine the presence of
homeless youth and the need for Street Outreach Services.
Procedure
Universal Child Abuse Prevention Services
STAR Contractors must document the type of activities and the number of
participants each month in the STAR database. The STAR program manager
must maintain documentation of all UCAP activities, along with a current
calendar of all events consistent with the UCAP table provided in the
approved Plan of Operations. Documentation may include copies of press
releases, notices or postings of upcoming activities in local newspapers,
flyers, and sign-in sheets or other documentation demonstrating the actual
number of attendees.
UCAP activities may include media campaigns, educational presentations,
parenting classes, participation in community-wide events, and public
awareness campaigns associated with Child Abuse Prevention Month and/or
other child abuse prevention campaigns.
Street Outreach Services
STAR Contractors must provide direct outreach to youth (especially urban
youth) who are homeless, disenfranchised, unsupervised, or at risk of
involvement with negative peer groups and/or gangs. These activities must
be documented in the STAR database each month.
9
FAQs
1. We serve a rural county with no homeless youth. Do we still
need to provide street outreach services?
As noted in the RFP, if the data reflect a low incidence of homelessness in a
county, and street outreach does not seem appropriate, the Contractor is
expected to perform an ongoing community assessment process to
determine if homeless youth are present and in need of services. The
presence of unsupervised youth or youth at risk of involvement with
negative peer groups/gangs would also be an appropriate target population
for street outreach.
2. Are there some resources we can use to get ideas for universal
child abuse/neglect and street outreach activities?
Yes. You can visit several websites to get ideas, such as the FRIENDS
Network (www.friendsnrc.org), the Center for Disease Control
(www.cdc.gov), the Substance Abuse and Mental Health Services
Administration (www.samsha.gov) and the Center for the Study of Social
Policy (www.cssp.org).
10
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Eligibility Criteria
STAR.7
September 1, 2012
STAR - Request for Proposal
Policy
Individual family members, as well as entire family units, may receive
services if any child or youth is identified as being at-risk for child
maltreatment and/or juvenile delinquency. The STAR program is intended
for youth and families who manifest risk behaviors and are experiencing:
•
Family conflict, for children and youth ages 0-17;
•
Truancy, for youth ages 10-16;
•
Runaway/homelessness, for youth ages 10-17; and/or,
•
Misdemeanor offense behaviors, for youth ages 10-16.
The appropriateness of STAR services is determined through an assessment
of the family and the presenting problem(s) or the reason(s) prompting the
request for services. The youth's or family's presenting problem must be
identified in order to provide STAR services.
Participation in services is completely voluntary and must be provided at no
cost to the youth or their family, without regard to the youth's or family's
income.
Eligibility Exceptions
STAR cannot provide services to the following:
1. CPS Involvement:
• If CPS in the process of an investigation of child abuse or neglect, STAR
contractors may not register the youth or family for services until the
CPS investigation is closed.
• A family with an open CPS case beyond the investigation stage, and
with the presenting problem of family conflict, may not be registered
for STAR services. However, if the youth presents with juvenile
delinquency as the presenting problem, and has an open CPS case,
STAR may provide services to address the juvenile delinquencyspecific issue.
11
•
Youth in the conservatorship of CPS are not eligible to receive any
STAR services, including emergency care services.
2. Juvenile Probation Involvement:
•
Youth who have been adjudicated and convicted of either a
misdemeanor or state jail felony offense are not eligible for STAR
services.
•
Youth whose cases are pre-adjudicated, informally adjudicated, or
whose adjudication has been deferred are eligible for STAR services.
FAQs
1. If a family comes in and indicates some CPS involvement or
investigation can STAR be billed for services?
If CPS is still in the investigation stage, the family cannot be served by
STAR. Once the investigation is considered closed, if the CPS case remains
open with the family, the youth can be opened as a STAR participant under
any other presenting problem, if the initial assessment indicates it is
appropriate. This will guard against potential conflict and/or duplication of
services.
2. In regard to CPS open cases, when you say to open them under a
different area, other than family conflict, does this mean runaway?
If the family has an open CPS case (not in the investigation stage), they are
already receiving services for family conflict from CPS. The youth can be
opened as a STAR participant under any other presenting problem, if the
initial assessment indicates it is appropriate.
3. If a child comes into the shelter and we later find out the youth
is on formal probation or involved in an open CPS case, will STAR
still reimburse us?
Youth in the conservatorship of CPS or on formal probation cannot be
served by STAR.
At intake, all eligibility criteria must be utilized to
determine if a youth can be served in the STAR program and this
information must be maintained and verified prior to providing services.
Contractors are expected to make a good faith effort to obtain this
information prior to serving youth and families.
12
4. We started serving a youth who was 17, but he turns 18
tomorrow. Do we have to stop serving him?
No.
You may continue to serve him after his 18th birthday until he
completes the program; he reaches 180 days of services within a 12-month
period; or the end of the fiscal year, whichever comes first.
13
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Registration Form 2075A
STAR.8
September 1, 2012
STAR - Request for Proposal & PEI
Supplemental
Policy
STAR contractors are required to record client data on the STAR Client
Registration DFPS Form 2075A during the intake and assessment process
and (1) maintain a copy of the form in the client file and (2) transfer data
from all the fields in the form over to the STAR database.
An asterisk (*) in a data field indicates a required field for the STAR
database. The current Form 2075A does not contain the asterisk at the
social security number (SSN) for the target youth at this time. However, it is
the expectation that STAR contractors will make all reasonable attempts to
obtain the youth and primary caregiver social security numbers. The SSN is
used as a means to track performance measures, both for youth that are
referred to the juvenile justice system and to ensure that children and
families remain safe.
Program forms giving consent for services are to be signed by the primary
caregiver prior to services being provided.
Procedures
1. Client Information - Social Security Number (Form 2075A, pg.
1)(optional field): Contractors are to make all reasonable attempts to
acquire the youth and primary caregiver's social security numbers. The
youth social security number is the identifying factor when DFPS performs a
tape match with external agencies, such as the Texas Juvenile Justice
Department (formerly known as Texas Juvenile Probation Commission and
Texas Youth Commission) and the primary caregiver's social security number
is the identifying factor for internal matches with Child Protective Service.
The primary caregiver's social security number is located on page 2 of Form
2075A.
If the youth or primary caregiver will not provide his/her social security
number, please indicate this on Form 2075A.
14
2. Other Family Members (page 2): Contractors are required to obtain
the names of all other family members or non-family members that reside
within the same residence as the youth. Contractors should indicate on Form
2075A if the other members will be participating in STAR services.
The other family members information should be cross-referenced in cases
with participating STAR eligible target youth.
3. Follow-Up Due Date: The Follow-up due date is the 75th day after
closure. The first follow-up date cannot be before the 75th day. For
example, a client's case is closed on 10/3/11, the Follow-up Date is
Saturday, 12/17/2011.
In the above example, if the contractor's first attempt is on the first business
day after the due date, or Monday, 12/19/2011, then on form 2075A, the
Date of 1st Attempt, the contractor would enter 12/19/2011. The contractor
will enter the dates of the subsequent 2nd and 3rd attempts to contact the
program participant. The 2nd and 3rd attempts cannot be made on the same
day as the 1st attempt, nor at the same time of day as the 1st attempt.
The contractor is required to make at least three attempts to contact the
program participant to obtain outcome information within 75 - 105 days after
case closure. The attempts may be in person, by telephone, or email, but if
the attempts are unsuccessful, the contractor must make a final attempt via
the postal service prior to the 106th day after case closure. All attempts to
complete the follow-up must be documented on the Client Registration Form
2075A and in the STAR database within 30 days.
Form 2075A Changes for Fiscal Year (FY) 2013
Enhancements have been made to Form 2075A for FY 2013.
Form 2075A includes a place for the Contract number, STAR contractor
name, contractor mailing address and contractor phone and fax numbers.
Client Information:
• Area Code/Phone Number - line 3 was deleted.
• Email Address 2 was deleted.
Youth's Living Situation:
• The "No" box has been added to the question; "Youth lives with or has
lived with a parent/relative sometime in the past 6 months."
Contributing Factors:
• Resources Referred check box and a line to enter where the client was
referred has been added.
15
Primary Caregiver's Information:
• Area Code/Phone Number - line 3 was deleted.
• Email Address 2 was deleted.
Other Family Members:
• The above has been e changed to read: "Other Family
Members/Other Participants:" (even if they are not receiving
services).
Follow-Up Information:
• The Follow-up Date was changed to: "Follow-up Due Date."
16
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
STAR Database Access - Log-In/Passwords
STAR.9
September 1, 2012
STAR - Request for Proposal
Policy
Contractors are required to enter client data into the STAR database within
30 days of the end of the month in which the client was served. Only eligible
clients entered into the database as served will be counted by PEI as having
been served by the program. STAR contractors and staff that will perform
data entry into the STAR database are required to submit the security
agreement DFPS Form 4020.
Procedures
Only contractor staff may have access to the database. If a contractor has
subcontractors, the subcontractors must submit their data to the contractor
and the contractor must enter all data into the database. It is recommended
that contractors have more than one staff member with access to the
database so that data entry can continue during times of extended absence;
however due to the sensitive nature of the information in the database and
the potential for corruption, it is also recommended that contractors limit the
staff that have database access to only key staff members.
A cleared Automated Background Check System (ABCS) background check
must be on file before database access will be granted. (Please see the
Background Check policy, located in the main PEI policy manual, for more
information.) A staff member must complete and submit an original, signed
Form 4020 before database access will be granted. In order for the Form
4020 to be considered complete, the following information must be included:
•
•
•
•
•
•
•
Contract number
Contractor name and address
Type of Access requested
User Information, including first and last name, address, social security
number, date of birth, work email, work telephone number, title, and
their security hint question and code (answer to security hint question)
Supervisor's name
Supervisor's signature and date
User's signature and data
Technical Assistance and Questions
A STAR Database User Guide is included as an attachment to this policy
manual. It is recommended that anyone who will be responsible for data
entry familiarize themselves with the user guide prior to using the database.
17
Some upgrades have been made to the database since the user guide was
created. Therefore, a user may encounter some changes not reflected in the
user guide and may need additional assistance.
Many questions about the database, such as how to enter data, which client
should get which service, which report to run and when, etc., should be
directed to the PEI contract manager. As they handle most database
queries, contractors should contact the contract manager for any database
question they don't know whom to ask.
For non-security technical assistance such as deleting clients from the
database, please contact the DFPS Contract Performance Division at
[email protected] Submission of a STAR Technical
Assistance Request (TAR) form is required if an action needs to be taken in
the database. A TAR form may be found on the "Welcome" page of the STAR
Database (the page with the "STAR Interface" button). Contractors should
always include their PEI program specialist on any emails to the Contract
Performance Division. A TAR form is also included as an attachment to this
manual.
For questions regarding system security, including issues with logging in or
passwords, please contact Daniela Rocha in the DFPS Program Support
Division at daniela.r[email protected]
FAQs
1. When I try to log in to the system, I receive the error message:
Invalid username and/or password.
This is typically caused when a user enters their username as
"tdprs\username." Remove the "tdprs\" prefix in front of the username and
try to log in again.
If you continue to have problems logging in, contact DFPS Program Support
at [email protected]
2. After logging in, I received the message "Your password has
expired." I tried to change the password but I get a message that
there are invalid characters in my username or password.
Enter your username as "tdprs\username" and try again.
Check the password criteria and make sure the password you are using fits
the required criteria.
If you continue to have problems logging in, contact DFPS Program Support
at [email protected]
3. Is it ok if I check the "Remember my password" checkbox on the
login page?
18
No. Due to security issues, this checkbox should not be checked. The login
box acts as an extra security precaution and bypassing it can potentially
allow unauthorized users to gain access to the sensitive client information
found in the database.
4. A co-worker needs access to the database but has not been
assigned a username and password. Can I log in for them?
No. Contracted providers must clear DPS, DFPS, and, if applicable, FBI
background checks in order to have access to the system. The system
contains sensitive client information (e.g., client names, addresses, DOB,
SSN), and this information must be protected from unauthorized users.
5. Can I share my login information with my coworker if they
already have access but they forgot their password?
No. As stated on page 2 of the 4020 Security Agreement, IDs and/or
passwords must be kept confidential and cannot be shared with anyone.
6. I am unable to log in to the Satisfaction Survey Interface using
my network login and password. What am I doing wrong?
To login to the Satisfaction Survey Interface, use your STAR password--not
your network password. This is the same password that you use to log in to
the STAR Interface.
7. I forgot my password or the system does not recognize my
password.
Contact DFPS Program Support at [email protected] and
request your password be reset.
8. How long does it take to reset a password?
Resetting a password may take a few hours to as much as a few days.
9. I am having problems logging in and I am worried about locking
my account. Is there anything I can do to avoid locking my account?
If you have tried to log in twice with no success, close your browser window,
re-open it and try again. This may be repeated up to two more times before
being locked out of your account.
If you continue to have problems logging in, you can try to close your
browser window, wait 10-20 minutes, and repeat the above steps.
If you are still unable to log in, contact DFPS Program Support at
[email protected]
19
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Service Unit Documentation
STAR.10
September 1, 2012
STAR Request for Proposal
Policy
Contractors are required to document ongoing services provided to the youth
and families. Program sign-in sheets with signatures, individual/group
progress notes, materials/hand-outs that support verification of participant
attendance to parent or youth skills group's needs to be maintained for
monitoring purposes. All program participants who receive services,
including Primary Caregivers, must be registered in the STAR database.
Procedures
The expectation is that all STAR services be conducted on a face-to-face
basis. PEI is aware that, occasionally, there may be an exception. Service
units should be entered into the database for the client participating in the
service. Please see the FAQ section for specific scenarios or contact your PEI
contract manager with specific questions.
FAQs
1. If a counselor meets ½ of a session with the individual and ½
with the family, how is the session counted?
The STAR-registered participant will receive 1 unit of Family Counseling.
2. Would email or phone calls between the family and counselor
count as an advisory service?
Phone calls and email contacts would not be considered a service for
purposes of reporting in the STAR database. You should continue tracking
these interactions in the case notes.
3. With regards to billing, do we report time or service units?
You will report the number of service units and attach a copy of the STAR
database Client Services Summary report to the freeze form when
submitting for reimbursement.
4. If a family receives two face-to-face visits within the same
month, are the service units counted as two units of service?
Yes, if they occur at two distinctly different times.
20
5. When seeing siblings (separately), are the total units entered
under the oldest sibling or is each sibling separate?
No. If each sibling is registered in the STAR database, either as a STAR
client or as an Other Family Member, they would each receive a unit of
service.
The service unit would be recorded in the STAR database
separately as a whole number.
6. If you meet with two family members together (example:
brother & sister) without a parent present, is this entered as a
Family Counseling?
No. If both youth are STAR-registered participants, they each would receive
one unit of Youth Counseling since there were no parents present. If only
one participant is registered in the STAR database, then that youth would
receive one unit of Youth Counseling.
7. Three youth are registered in the STAR database and the
counselor has a family session with two of the youth and the
primary caregiver.
Would the third youth receive a family
counseling unit if the STAR counselor worked with the primary
caregiver about ways to deal with the third youth?
Yes. Each STAR-registered youth would receive a unit of Family Counseling.
8. If a counselor meets with a parent, who has children receiving
STAR services, and talks to the parent about the children, (i.e.,
discussing the youths' action plans, etc.) without the children
present, do all siblings get a unit of service and which one would
they get?
Yes. Each STAR-registered youth would receive one unit of Family
Counseling.
9. If you have three youth (siblings) who are all STAR-registered
participants in a session with no parent/guardian present, should
this session be reported as one unit of Youth Counseling for each
youth?
Yes. Each youth will receive one unit of Youth Counseling.
21
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Request to Unfreeze a Month
STAR.11
September 1, 2012
STAR Request for Proposal
Policy
Contractors are required to enter program data including, but not limited to:
•
•
•
•
•
Client registration information
Service data
Youth/Primary Caregiver Satisfaction Survey Questionnaire data
Pre- and Post-Protective Factors Surveys
Case closure and follow-up information for all registered clients.
The contractor should ensure that all data for a specific month are entered
into the STAR database within 6 days of the close of the month of service,
but contractors must ensure that all data is entered no later than 30 days
following the close of the month of service.
When submitting their billing each month, contractors must also submit a
"freeze form" that locks the service unit data for that specific month. Once
the PEI contract technician has received and processed the bill for the month,
the data for the month will be locked, or "frozen", and no additional data
entry can be made for that month unless the contractor requests to have
that month's data unfrozen.
Procedure
If a contractor has a data entry error, such as missing service units or an
incorrect number of service units, the contractor must request that the
month with the error be "unfrozen." Note: If a month is unfrozen, it cannot
be "refrozen."
Here are the steps to unfreeze a month:
1.
Contact your STAR contract manager in PEI and request that the records
be unfrozen in the STAR database.
2.
The contract manager will send a request to DFPS Contract Performance
to unfreeze the specific month in question. The request can only be for
the time period during the current fiscal year. The contract manager
will copy the contract technician on the request.
22
3.
Once the month is unfrozen, the contract manager will notify the
contractor to make the necessary data entries or corrections.
FAQs
1. I am trying to enter services for a client but the services for that
month are frozen. What should I do?
Services are frozen after the end of each month by the contract technician
upon receipt of that month's billing and freeze form. Contact your STAR
contract manager in PEI and request that the records be unfrozen in the
data system.
2. I have finished entering services for a month that was unfrozen.
How do I have the services for that month frozen again?
A month that was unfrozen cannot be frozen again.
3. Will a request to unfreeze a month count against us?
The introduction of new data will appear as late data entry on the Timely
Data Entry STAR database report.
23
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Technical Assistance Request (TAR) Form
STAR.12
September 1, 2012
STAR Data System User Guide
Policy
PEI requires contractors to use the Technical Assistance Request (TAR) form
for any request that requires an action be taken in the database.
If you have a simple question about the functionality of the data system, and
you are unable to find the answer in the STAR Data System User Guide, you
may email DFPS Contract Performance at
[email protected] with your question.
A TAR form is not needed for any requests involving your password as those
requests must be sent to DFPS Program Support at
[email protected]
Procedures
Most data entry fields in the database are editable by the contractor. Thus, if
the contractor makes an error during data entry, the contractor can easily
correct the error. Errors to service units can be made by a contractor before
the data are frozen. For information about changing data after it has been
frozen, please see the policy, "Request to Unfreeze a Month," within this
policy manual.
However, the following issues require the submission of a TAR form:
•
Delete a duplicate registration or client
•
Delete Incorrect Family Member Added/Attached to Registration
•
Unlock Protective Factor Surveys if data entry error is made on the Pre- or
Post-Protective Factor Survey
•
Correct or remove registration close date and outcome information
•
Correct or remove registration follow-up date and outcome information
•
Delete universal services
•
Delete crisis intervention calls and walk-ins
24
•
Report if any database reports are not generating or calculating correctly;
or
•
Report receipt of an error message in the data system.
The TAR form is located on the STAR home page of the database as a link
(STAR Technical Assistance Form). To submit a TAR form follow the
following the steps:
•
It is recommended that you save a copy of the TAR form to your
computer.
•
Complete the form; required fields are designated with a red asterisk (*).
•
Be sure to include the Name and Client ID number of the Target Youth or
other family member.
•
Please enter only one registration ID number per form.
•
You must describe what action is needed and what caused the problem in
detail.
•
E-mail the form to DFPS Contract Performance at
[email protected]
FAQs
1. I received an error message while working in the database. What
should I do?
Take a screenshot of the error message, write down the steps you took
immediately before the error occurred, and send it to DFPS Contract
Performance at [email protected]
2. How do I take a screenshot?
Hold down the Alt key and press the Print Screen (PrtScn) key on your
keyboard. Paste the image in a Word document or in the body of an email.
25
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
STAR Action Plans
STAR.13
September 1, 2012
STAR Request for Proposal
Policy
The contractor must engage the participants in the development of an Action
Plan prior to initiating services once the intake and assessment has taken
place. The Action Plan must be completed within three (3) days of the initial
assessment, reviewed every 30 days thereafter, and include goals and steps
the youth and caregiver have agreed to work on during services. The Action
Plan should be viewed as a brief social contract, but is not intended to be a
diagnostic or prognostic therapeutic document.
Procedure
1. STAR Action Plans must:
• Be family-focused;
• Identify the specific behavioral changes or actions that each
participating family member has committed to make so they can
address the presenting problem;
• Be written in the language of the client where it can be easily
comprehended and clearly understood by the youth and family;
• Contain specific STAR services to be provided to the youth and family
members;
• Document other resources or referral offered to the participants;
• Be updated with the client at least every 30 days with progress
toward goals documented and any new goals/tasks;
(Note: Clients should add or change the goals or tasks if they are not
having success with previously stated goals/tasks.)
• Be signed by the target youth and all participating family members
with a copy provided to all participants; and,
• Be maintained in the client case file.
2. Guidelines for Goals
• Goals must be important to the person. Clients are more motivated to
work towards goals they agree with.
• Goals must be small, simple, and realistically achievable. The smaller
the better to ensure client success.
• Goals are described through discussion. Clearly state the expectation
of each family member.
26
•
•
•
•
Goals must be stated as the presence of something, such as help the
person find the presence of a desirable replacement behavior;
something they will be doing.
Goals must be described as a beginning of a new behavior, not the end
of undesirable behavior. When people state goals as idealistic they
may take a long time to achieve. Therefore, help the person to shape
a goal that begins to move them in the direction they want to go,
using language like, "cleans room three times a week without
direction," or "turns homework in on time at least 4 out of 5 times."
Goals should be as specific as possible. Specific goals include
behavior, action, cognition, feeling state, verbalization and specifically
where and with whom it will occur.
Goals should be small, attainable, and measurable. For example: "Will
set alarm clock for 6:00 am the night before I have to wake up on
Monday and Tuesday this week", or "Mom will remind Johnny to
complete his English homework after school on Monday through
Friday", and "I will attend Math class on Monday, Tuesday, and
Friday".
3. Quantify vague goals
• When people are hesitant to describe their goals in behaviorally
specific, action-based terms, ask them to quantify, rate or scale their
problem before finding action steps they can take to improve their
rating.
• Use multiple-choice question to clarify goals. When people have
difficulty specifying goals, ask them if they want option A, option B or
option C.
• Goals are stated in a process form, or action-based. Use '-ing' words
such as "going to school, doing homework."
Attachment B is the revised Fiscal Year 2013 Action Plan template.
27
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
STAR Performance Measures and Reporting
STAR.14
September 1, 2012
STAR - Request for Proposal and Form 2282
Contract Boilerplate-PEI Supplement
Policy
Performance Measures
Pursuant to the Texas Human Resources Code §40.058 (effective September
1, 2005), all contracts for client services must include clearly defined goals
and outcomes that can be measured to determine whether the objectives of
the program are achieved. DFPS is committed to implementing
performance-based contracting methods that structure all aspects of the
contracted services around the purpose of the work to be performed and the
desired results.
Contractors' performance requirements are defined by DFPS. DFPS reserves
the right to renegotiate performance measures, indicators, and/or targets at
any time.
The STAR performance measures include both outputs and outcomes.
Output measures demonstrate performance in terms of the quantity or
volume of services provided (i.e., the number of participants served, number
and types of services, etc.). Outcome measures demonstrate performance in
terms of quality and impact of services, and whether or not they have met
the intended goal of the contract. Outcomes relate to changes in behavior,
skills, knowledge, attitudes, values, etc.
If a Contractor's performance is five percent or more over or under the
established output target or five percent or more under an established
outcome target, the contractor must submit a variance statement explaining
the discrepancy. Variance statements must be submitted by deadlines
established by DFPS.
Note: The five percent variance applies to all outputs and
outcomes, except Outcome #2: Target Youths will remain safe.
Contractors are expected to achieve 100 percent of this target
measure for the year.
Reporting
All PEI Contractors are required to regularly pull and review PEIS data
reports to ensure satisfactory progress toward contract and program goals.
PEI contractors are required to enter client information, service data, and
protective factor survey data into the STAR database.
28
PEI contractors are required to download and review performance
measure reports from the STAR database on a monthly basis.
If the contractor's review of reports identifies a contractor is off track to
meet their annual performance measures, or other contract requirements,
a corrective action plan to address the performance measure or contract
requirement must be submitted at least quarterly.
All database reports that reflect performance measures, along with all
corrective action plans created to address challenges, must be submitted
to PEI staff not later than 15 calendar days after the end of the first,
second and third quarters.
Procedures
1. Each month contractors will download reports that provide information on
progress toward the completion of contract requirements and
performance measures. Here is a list of the required reports and the
performance measures tracked on each one:
Provider Summary Report: Use this report to track the average
number of Target Youths served monthly.
Performance Measures Report (titled the Output, Efficiency, and
Outcome Measures on the report itself): Utilize this report to track
Output#2 Number of target you the served during the contract period
and Output #3 Pre- and Post-Protective Survey Questionnaires
completed by primary caregivers.
PEI Provided Information: As there are not STAR database reports
that currently track Outcome #1 an increase in the score for at least
one protective factor by unduplicated families, Outcome #2 Target
Youths will not engage in delinquent behavior, or Outcome #3 Target
Youths will remain safe, PEI will periodically provide this information to
contractors during the contract year, as the information is available.
2. After all reports are downloaded, contractor staff will review these reports
and assess any areas where they are not currently meeting, or are off
track to meet, performance measures or contract requirements.
3. While STAR contractors will not be expected to complete any quarterly
reports, they are expected to submit the database reports they run
monthly and the completed Quarterly Ongoing Monitoring and Database
Reports form (see Attachment D). These items must be submitted by
(postmarked no later than) December 15th, March 15th, and June 15th of
each year.
4. For each output or outcome not currently on target, the contractor must
complete the appropriate section of the Quarterly Corrective Action Plan
form (see Attachment E). The Corrective Action Plan must then be
implemented by the contractor in an effort to get back on track to meet
the deficit target(s).
29
5. An annual report should be completed and submitted on October 15th,
following the end of the fiscal year for which it's being completed. The
PEI contract manager will provide the annual report template.
FAQs
1. Is there a report that shows all the Pre-Protective Factor Survey
questionnaires entered?
The Client PFS listing in the STAR database reflects only the names of the
clients that had the Pre and Post-PFS data entered.
2. I have completed my monthly review, and I cannot determine
which Client PFS I have failed to enter. Is there a report that I can
use?
No. You can however, generate the Client PFS listing above, copy the report
to Excel and sort by the date. You can also do the same with the Client
Services Summary. Sort by the date and compare the client names within
the same time period.
3. I have completed my monthly review, and completed Pre- and
Post-PFS is at 56%. Is this considered on track?
Yes, there is a 5% variance with most performance measures (the
exceptions are the measures relating to children remaining safe and youth
not participating in delinquent activity). However, the expectation is to be
on target, or exceeding the target, each reporting period.
4. Which report do I review to determine if the agency is meeting
the contracted PFS target measures?
Review the Output, Efficiency and Outcome Measures (Performance
Measures) report. Scroll down to the heading: Target Youth Pre-and PostProtective Factor Completion section. In the table with Columns A - E,
Column C will provide you with the number of completed Pre- and Post-PFS
for tracking purposes with target youth.
30
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
STAR Payment Methodology
STAR.15
September 1, 2012
STAR Request for Proposal
Policy
The contracts awarded under this procurement will be paid on a fee-forservice and limited cost-reimbursement payment basis.
The rate is not negotiable and will remain the same for the
life of the procurement.
Consistent with federal and state regulations, DFPS is not obligated to pay
unauthorized costs or to pay more than contractor’s allowable and actually
incurred costs. Contractors are responsible for submitting bills in an accurate
and timely manner.
For the cost-reimbursement portion of the contract:
The contractor will remain in compliance with 45 CFR Part 74 as applicable,
Office of Management and Budget (OMB) Circulars A-133, A-110, A-21, A-87,
and A-122 as applicable, the Uniform Grant Management Standards (UGMS)
as applicable, and 40 Texas Administrative Code (TAC) §§732.240–256 as
applicable. The reimbursement made to Contractor will not exceed the
contractor’s actual costs to provide the services under this contract and
contractor’s actual costs, both direct and indirect, must be allowable,
reasonable, and allocable.
For the fee-for-service portion of the contract:
Fees charged for this contract must be supported by adequate
documentation reflecting that services were provided according to the RFP
and any applicable policies.
Procedures
For those limited items that will be paid via the costreimbursement payment method:
After the costs have been incurred, submit a completed Form 4116 Purchase
Voucher and a billing spreadsheet delineating the expenses that will be cost
reimbursed.
31
Note: supporting documentation of all costs associated with the expenses
that are paid via the cost-reimbursement payment method must be
maintained and presented when requested.
For all other costs, which are included in the Fee-for-Service
payment method:
After completion of the month, the Contractor should submit a Form 4116
Purchase Voucher and a completed Freeze and Billing form. The contractor is
responsible for ensuring accurate billing related to the Fee-for-Service rates,
including the number of clients served and the number of sessions billed.
PEI staff will routinely verify the information provided.
Only sessions and services provided to clients that are eligible for the STAR
program must be submitted for payment.
FAQs
1. I facilitated a skills group session which required both the
primary caregiver and youth to be in attendance with multiple
families. How do I bill this service?
The billing rate will be Family Skills Group, even though more than one
family was in attendance.
2. I facilitated a group session with the Primary Caregiver(s) in a
session and the youth(s) in a session with different counselors.
How do I bill these services?
Each Primary Caregiver in the session will be billed at the Family Skills
Group rate, and the Target Youth will be billed at the Youth Skills Groups
rate.
3. The Primary Caregiver and the Secondary Caregiver came for a
session, the target youth was not in attendance. How do I bill this
service?
The service will be billed as a Family Counseling Session.
4. The Primary Caregiver and the Target Youth had an appointment
for counseling services. The Primary Caregiver did not appear, the
counselor met with the youth only. How do I bill this service?
The service should be billed as an Individual Youth Counseling Session.
32
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Service Time Limits
STAR.16
September 1, 2012
STAR Request for Proposal
Policy
STAR services are designed to be short-term and are therefore time-limited.
Clients who enroll in the program may not receive services for more than 180
days in a 365 day, or 12-month, period. This is a rolling 12-month period,
which means the 12-month period includes the 365 days preceding the
current day of service and the current day of service. Once a client has met
the 180-day limit, they may not be served again until the 366th day when
they have no longer exceeded 180 days within a 365 day period.
The STAR database automatically tracks which clients are nearing the 180th
day of service. Once a client has reached the 181st day of service,
contractors may no longer bill for services provided to the client.
Procedure
Contractors should monitor which clients are nearing the 180th day of service
within a 12-month period by frequently running the Clients w/160+Days
Open Registration report. Note that having an open registration constitutes
having a date of service, even if no services were provided on every day the
registration was open.
Contractors should inactivate client registrations for clients who are not
actively receiving services. They should do so effective the day after the last
date of service, in order to ensure that clients receive the maximum amount
of service dates possible.
As noted earlier, contractors may not bill PEI for services
received by a client after the 180th day of service within a 12month period. Contractors should ensure they are not providing
services to any clients who have exceeded the service time limits
and should ensure that they do no bill for any services provided
to clients who received services after the 180th day of service.
33
FAQs
1. We have a client who really needs services, but they have been
receiving services for 180 days already. Can we continue to provide
services to them? Maybe through a variance or something?
No. A contractor may not exceed the 180 days of service within a 12-month
rolling period for any client, regardless of the reason. Variances will not be
granted.
2. Why doesn’t the 180 service days requirement follow the fiscal
year?
The STAR database is currently designed to follow a 180 days of service
period during a 12-month rolling cycle and, unfortunately, due to limited IT
support, this is not expected to change for several years.
3. What happens if we bill you for a client who has exceeded the
180 days?
If you are inadvertently paid for a client who had exceeded the 180 days
within the 12-month period, you will be expected to reimburse DFPS for the
money.
34
Policy Title
Policy Number
Effective/Revision Date
Authority/Reference(s)
Telemedicine
STAR.17
September 1, 2012
STAR Request for Proposal
Policy
Face-to-face counseling sessions are strongly preferred and should represent
the majority of counseling sessions provided to clients served in the STAR
program. On rare occasions when it is not possible to schedule a face-toface counseling session with a client, a contractor may utilize phone
counseling, online counseling, webinars, or video conferencing, within certain
parameters.
First, the confidentiality of the client must be ensured when utilizing an
alternate form of counseling. Contractors who opt to use telemedicine must
use encrypted technology to ensure that the session is not in danger of being
hacked or otherwise infringed upon. Media such as Skype, Facebook
messaging, Twitter messaging, online chat rooms, FaceTime, unencrypted
webcams, etc., may not be used. Cell phone usage for phone counseling is
also strongly discouraged.
Second, contractors may only bill for counseling sessions that have occurred
face-to-face. Contractors may track the alternate forms of counseling
sessions that have occurred; however, they may not bill for those sessions.
Procedures
Contractors who will opt to use telemedicine technology should notify their
PEI contract manager of this plan and include what steps they will take to
ensure client confidentiality. The contractor should also include how they will
track the difference between face-to-face sessions and other types of
counseling sessions to ensure that billing is accurate.
While PEI recognizes that telemedicine can be beneficial when
used properly, the primary concern must always be client
confidentiality and safety.
35
FAQs
1. We didn’t include telemedicine in our original plan of operations,
but would like to offer phone counseling. How do we go about
adding that?
You would need to submit a plan change to your PEI contract manager. The
plan change should include:
An effective date, which should be at least 30-days from the date of the
letter;
Your plan for ensuring client confidentiality, and how you will track
phone counseling sessions separately from face-to-face counseling
sessions to ensure proper billing; and,
Any other information you believe is pertinent to the request.
2. I understand we can’t bill for phone counseling sessions, but
video conferencing sessions are just like face-to-face sessions. Why
can’t we bill for them?
While video conferencing sessions are similar to face-to-face counseling
sessions, they are not identical and cannot be billed to PEI. Face-to-face
counseling sessions must take place while both the counselor and the client
are in the same room and present in each other’s company.
36
ATTACHMENT A
SERVICES TO AT-RISK YOUTH (STAR) CLIENT REGISTRATION (FORM 2075A)
Intake Staff Initials
Therapist Initials
Date of Intake
Rev 9/1/12
Data Entry Staff
Date of Data Entry
Other Dates
Contract Number: __________
Provider Name: _______________________________________________________________
Provider Mailing Address: ___________________________________________________________________________________
Provider Phone: ( )
Fax: ( )
CLIENT INFORMATION (* indicates required field)
Youth Client ID:
* Youth First Name
* Youth Last Name
*Gender:
Male
Female
Suffix:
*Date of Birth:
*Ethnic Group (select one):
Hispanic
Non-Hispanic
Unable to Determine
*County Number:
*Client Address:
*Street:
*City:
*State
TX
*SSN:
*Race (select all that apply):
Native Hawaiian/Pacific
Am Indian/Ak Native
White
Asian
Unable to Determine
Black
Colonia Name (if applicable):
Area Code/Phone Number
Home/Work/Cell
1)
H
W
C
2)
H
W
C
County Name:
*Zip
Youth Reg. ID:
Middle Name
Email Address 1
*CLIENT’S PRESENTING PROBLEM (Select One) (Registration Continued Tab in STAR database)
Delinquent Behavior
Misdemeanor Offence
Offence
At Risk Youth
Family Conflict
Core Service:
Runaway
Truant
Crisis Family/Youth Counseling
Youth Coping Skills Training
Is there an open CPS case?
Yes
State Jail Felony Offence
Emergency Care Services
Parent Skills Training
*School Status When Entering Program (Select One):
Attending Regularly
Attending-Some Truancy
Suspended
Expelled
Has Youth been homeless in the past 12 months:
Offense Code:
Yes
Youth Under 10 Delinquent
Family/Youth Short-term Counseling
Telephone Services
Dropped Out
Parent Withdrawn
Alt. Sch./GED/Homebound
Graduated High School
School Not In Session
Completed GED
Under School Age
No
Is Youth adjudicated or on probation?
No
Yes
No
*Referral Source (Select One):
Self (Youth)
Parent/Guardian
Friend/Relative
Provider Agency Staff
School
Protective Service
Texas Youth/Runaway Hotline
Law Enforcement
* Youth’s Living Situation (Select One):
With Biological/Adoptive Parents
With Legal Guardian
Unstructured Sub. Care (friends)
Structured Substitute Care
*The family earns less than $63,000
per year.
Yes or
No
Primary Language Spoken in home:
Juvenile Probation
Clergy/Church
MHMR
Other Private Agency
Street
Secure Facility Detention Ctr.
Relative’s Home
Psychiatric Hospital
*Youth lives with or has lived with a parent/relative
sometime in the past 6 mos.
Yes or No
English
Spanish
Vietnamese
Contributing Factors (Check all that apply):
37
Other
Other Youth Service Agency
Other Hotline
Court Ordered
Living Independently
Emergency Shelter
No Stable Living Environment
*The crisis did not occur because a family member
refused employment or training for employment.
Yes or
No
SERVICES TO AT-RISK YOUTH (STAR) CLIENT REGISTRATION (FORM 2075A)
1. Family Conflict/Violence
2. Youth’s Assaultive Behavior
3. Youth’s Problems w/Juvenile Justice
4. Youth’s Drug/Alcohol Abuse
5. Youth has Suicidal Thoughts
6. Youth Attempted Suicide in Past
Rev 8/16/11
7. Past Victim of Child Abuse
8. Other:
Resource Referred:
_____________________________________________
Division of Prevention and Early Intervention, DFPS
Page
38
ATTACHMENT A
SERVICES TO AT-RISK YOUTH (STAR) CLIENT REGISTRATION (FORM 2075A)
PCG Client ID:
PCG Reg. ID:
* Primary Caregiver's Last Name
* First Name
Marital Status: Single
Relationship to Youth:
Married
Separated
Aunt
Brother
Father
Female Cousin
Yes
*Zip:
*Gender:
Male
Female
Unknown
Date of Birth:
Suffix
SSN:
Stepfather
Stepmother
Uncle
No If no, please complete address and phone information.
County Name:
Colonia Name (if applicable):
Area Code/Phone Number
1)
2)
Home/Work/Cell
H
W
C
H
W
C
Email Address 1:
*Ethnic Group (select one):
Hispanic
Non-Hispanic
Unable to Determine
Marital Status: Single
Relationship to Youth:
Middle Name
Mother
Other, Non-Related
Other, Related
Sister
Race (select all that apply):
Am Indian/Ak Native
Asian
Black
SCG Client ID:
Secondary Caregiver's Last Name
Aunt
Brother
Father
Female Cousin
Gender:
Male
Female
Widowed
Grandfather
Grandmother
Legal Guardian
Male Cousin
Address same as Youth?
*County Number:
*Client Address:
*Street:
*City:
*State: TX
Divorced
Rev 9/1/12
Married
Separated
Native Hawaiian/Pacific
White
Unable to Determine
SCG Reg. ID:
First Name
Divorced
Widowed
Middle Name
Unknown
Legal Guardian
Grandfather
Grandmother
Male Cousin
Ethnic Group (select one):
Race (select all that apply):
Hispanic
Am Indian/Ak Native
Non-Hispanic
Asian
Unable to Determine
Black
Date of Birth:
Suffix
SSN:
Mother
Other, Non-Related
Other, Related
Sister
Stepfather
Stepmother
Uncle
Native Hawaiian/Pacific
White
Unable to Determine
Other Family Members/Other Participants: (Even if they are not receiving services)
Last Name
First Name
Date of Birth
Age
Relationship to Youth
Will participate in family
Sessions (yes, no)
Optional Questions
Own
Family Housing:
Rent
Primary Caregiver's Education Level:
Pre K/Kinder
3rd grade
1st grade
4th grade
2nd grade
5th grade
Secondary Caregiver's Education Level:
Pre K/Kinder
3rd grade
1st grade
4th grade
2nd grade
5th grade
Homeless
Temporary Shelter
Temporary with Relatives/Friends
Shared Housing with Relatives/Friends
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Did Not Graduate
Graduated H.S./GED
Some College
College
Post Graduate
Unknown
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Did Not Graduate
Graduated H.S./GED
Some College
College
Post Graduate
Unknown
Permissions (Check all that apply):
Messages may be left on my voice mail.
Mail may be sent to my home.
E-mail may be sent to me.
Agency staff (besides counselors) may contact me.
Required Signature
I certify that, to the best of my knowledge, the above information is true and correct, and I authorize services.
Printed Name of Parent or Legal Guardian
Signature of Parent or Legal Guardian
39
Date
ATTACHMENT A
SERVICES TO AT-RISK YOUTH (STAR) CLIENT REGISTRATION (FORM 2075A)
Youth Client ID:
Youth Last Name:
Rev 9/1/12
Youth Reg ID:
First Name:
CLOSE CASE INFORMATION
Middle Name:
Close Date:
Has Youth been homeless in the past 12 months:
Yes
No
Youth’s Living Situation (select one):
With Biological/Adoptive Parents
Street
Living Independently
With Legal Guardian
Secure Facility Detention Ctr.
Emergency Shelter
Unstructured Sub. Care (friends)
Relative’s Home
Structured Substitute Care
Psychiatric Hospital
Answer the appropriate question relating to the Youth’s presenting problem (select one):
Is family conflict situation:
Was youth truant during services?
5. Better
6. Same
7. Worse
4. No
3. Yes
22. Yes, but less often
Did youth run away during services?
Delinquent behavior – subsequent development:
2. No
1. Yes
21. Yes, but less often
8. Another Offense
9. Been Arrested
11. No More Offenses
* Current School Status (Select One):
Attending Regularly
Attending-Some Truancy
Suspended
Expelled
Reason for Closure (select one):
Successfully completed services
Discontinued services
Dropped Out
Parent Withdrawn
Alt. School/GED/Homebound
Graduated High School
CPS case opened
Maximum allowable services provided
School Not In Session
Completed GED
Under School Age
Youth/Family location unknown
Youth adjudicated delinquent
Other
Closure Comments (optional) (e.g., best time to call):
* Referrals Made (check all that apply):
Additional Social Services
Respite
Child Care
Long Term Counseling
Medical Services
TWC (Job Skills/Employment Services)
Legal (Legal Aid/Child Support/Attorney General Office - Child Support Division)
MHMR (Mental Health/Mental Retardation Services)
Social Security Administration
Emergency Assistance (Rent, Utilities, Food Clothing)
Domestic Violence Shelters/Services
Runaway Shelter/Services
Insurance (Chip, Medicaid)
Other: ___________________________________________________________________________
40
ATTACHMENT A
SERVICES TO AT-RISK YOUTH (STAR) CLIENT REGISTRATION (FORM 2075A)
Youth Client ID:
Youth Last Name:
Youth Reg ID:
First Name:
Rev 9/1/12
Middle Name:
FOLLOW UP INFORMATION
Follow Up Due Date:
Youth’s Living Situation (select one):
With Biological/Adoptive Parents
Street
Living Independently
With Legal Guardian
Secure Facility Detention Ctr.
Left Program, Location Unknown
Unstructured Sub. Care (friends)
Relative's Home
Emergency Shelter
Structured Substitute Care
Psychiatric Facility
Answer the appropriate question relating to the Youth’s presenting problem (select one):
Is family conflict situation:
Has youth been truant since services were terminated?
5. Better
6. Same
7. Worse
4. No
3. Yes
22. Yes, but less often
Has youth runaway since services were terminated?
Delinquent behavior – subsequent development:
2. No
1. Yes
21. Yes, but less often
8. Another Offense
9. Been Arrested
11. No More Offenses
Did the services help your family?
Yes, a lot
Yes, some
No
For truancy, delinquency and runaway presenting problems, Is the situation:
Better
Same
Worse
Contact Person :
Youth
Secondary Caregiver
School Contact
CPS
(select one)
Primary Caregiver
Other (not specific)
JJ Contact
Other family member
Has Youth been homeless in the past 12 months:
Yes
No
Date of 1st Attempt:
Date of 2nd Attempt:
Date of 3rd Attempt:
Follow-Up Comments (optional) (e.g., number disconnected, family moved, etc.):
41
ATTACHMENT B
STAR Program
Action Plan for FY 2013
Initial
Update
Client Name: ________________________
Age:______
Primary Caregiver: ________________________
Date: _____________
Relationship: _____________________
Issues of concern:
Core Service Type:
Location: Office
Youth
Home
Family
School
Overall Family Functioning:
Goal # ______
Low
Family Skills
Other
1
Current Functioning:
2
3
4
Low 1
5
2
Tasks (What will it take to achieve goal?)
Goal # ______
Youth Skills
6
3
7
4
8
5
9
6
10
7
High
8
9
10
Responsible Person(s)
Current Functioning:
Low
Tasks (What will it take to achieve goal?)
1
2
3
4
5
6
High
Target
7
8
9
10
Responsible Person(s)
High
Target
I/We participated in the formation of this Action Plan. I/We agree to cooperate with and participate in the process of achieving the started goals. I/We
understand that I/We may withdraw from this agreement at any time.
Copy given to family: _____ Date:________
Next appt date:_____________
__________________________________________
____________________________________
Youth
Date
________________________________________
Other Family Member
Date
__________________________________________
STAR Caseworker
Date
Primary Caregiver
Time:_______
Date
_______________________________________
Other Family Member
Date
_____________________________________
STAR Program Manager
42
Date
ATTACHMENT C
FY 2013 Performance Measures for
Services to At-Risk Youth (STAR) Program
Procurement Number: 530-13-0001
Goal of the Contract: To provide crisis intervention to at-risk youth and their families to restore family stability
and adaptive crisis resolution to prevent incidence of child maltreatment and juvenile delinquency
Output Measures
Output #1: The expected average number of Target Youths are served monthly.
Performance Period: Contractor performance for this output is determined for each month of the contract
period, either wholly or partially, depending on the contract start and end dates.
Indicator: Average number of unduplicated Target Youths served in the Contractor’s STAR Program each
month
Target: The target for this output measure may be negotiated.
Purpose: To evaluate the Contractor’s effort at providing services to Target Youths in the STAR Program
Data Source: STAR Database
Methodology: The numerator is the total number of unduplicated Target Youths served by the Contractor during
the most recent completed month, added to the total number of unduplicated Target Youths served by the
Contractor during each previous completed month (if any). The denominator is the total number of completed
months. Divide the numerator by the denominator.
Output #2: The expected number of Target Youths are served during the contract period.
Performance Period: Contractor performance for this output is determined annually but measured monthly
throughout the contract period.
Indicator: Total number of unduplicated Target Youths served in the Contractor’s STAR Program during the
contract period
Target: The target for this output measure may be negotiated.
Purpose: To evaluate the Contractor’s effort at providing services to Target Youths in the STAR Program
Data Source: STAR Database
Methodology: Total the number of Target Youths with unique client ID numbers who were served by the
Contractor during the contract period.
Output #3: Pre-Service and Post-Service Protective Factors Survey Questionnaires are completed by the
Primary Caregivers served.
Performance Period: Contractor performance for this output is determined annually but measured quarterly
throughout the contract period.
Indicator: Percentage of eligible Primary Caregivers from whom completed Pre-Service Protective Factors
Survey Questionnaires and matching Post-Service Protective Factor Survey Questionnaires are obtained by the
Contractor
Target: 60%
Purpose: To evaluate the Contractor’s effort at obtaining outcome data
Data Sources: STAR Database
Methodology: The numerator is the number of eligible Primary Caregivers served by the Contractor during the
contract period from whom completed Pre-Service Protective Factors Survey Questionnaires and matching Post-
43
ATTACHMENT C
Service Protective Factor Survey Questionnaires were obtained. The denominator is the total number of eligible
Primary Caregivers served by the Contractor during the contract period. Divide the numerator by the
denominator, multiply by 100 and state as a percentage.
Outcome Measures
Outcome #1: An absolute increase in the score for a minimum of one protective factor is reported by
unduplicated families served.
Performance Period: Contractor performance for this outcome is determined annually but measured quarterly
throughout the contract period.
Indicator: The number of Protective Factors Survey subscales (protective factors) for which 75% of the Primary
Caregivers indicate an absolute increase by comparing Pre-Service Protective Factors scores to Post-Service
Protective Factors scores
Target: One protective factor for which 75% of primary caregivers indicate an absolute increase (The
Contractor’s ability or inability to meet or exceed this target will not be the sole means for assessing their success
in providing the contracted client services. DFPS reserves the right to revise the target for this outcome measure
for any subsequent contract periods based on statewide Contractor performance data.)
Purpose: To evaluate the Contractor’s success at increasing protective factors in families who are served by the
Contractor’s STAR Program
Data Sources: STAR Database
Methodology: For each eligible Primary Caregiver from whom both Pre- and Post-Service Protective Factors
Survey Questionnaires are obtained by the Contractor:
1. Calculate the scores of each protective factor in each Pre-Service Questionnaire and each Post-Service
Questionnaire per instructions in the Protective Factors Survey User Manual.
2. For each set of matching Pre- and Post-Service Questionnaires from the same Primary Caregiver,
subtract the score of each protective factor in the Pre-Service Questionnaire from the corresponding
score in the Post-Service Questionnaire.
3. For each protective factor, count the number of Post-Service Questionnaires that indicate an increase in
the score.
4. For each protective factor the numerator is the total number of Post-Service Questionnaires counted in #3
that indicate an increase in the score. The denominator is the total number of Post-Service
Questionnaires for which the protective factor score was calculated. Divide the numerator by the
denominator, multiply by 100 and state as a percentage.
5. Total the number of protective factors for which the percentage calculated in #4 equals 75% or more.
(The Contractor must meet or exceed the target for Output #3 in order to achieve the target for this
outcome.)
Outcome #2: Target Youths will not engage in delinquent behavior.
Performance Period: Contractor performance for this outcome is determined annually but measured quarterly
throughout the contract period.
Indicator: Percentage of 10-16 year old Target Youths that are not referred to a county juvenile probation
program while receiving services from the Contractor’s STAR Program for a presenting problem of juvenile
delinquency
Target: 95%
Purpose: To evaluate the Contractor’s success in providing services that deter delinquent behavior in 10-16 year
old Target Youths receiving services from the STAR Program
Data Sources: Texas Juvenile Justice Department (TJJD) and STAR Database
Methodology: The numerator is the total number of unduplicated 10-16 year old Target Youths served during
the contract period for a presenting problem of juvenile delinquency who were also referred to a county juvenile
probation program while receiving services from the Contractor’s STAR Program. An existing protocol for
matching youth data maintained in the STAR database with youth data maintained by TJJD will be used to
44
ATTACHMENT C
establish the numerator. The denominator is the total number of unduplicated 10-16 year old Target Youths
served in the Contractor’s STAR Program during the contract period for a presenting problem of juvenile
delinquency. Divide the numerator by the denominator, subtract this number from one, multiply by 100 and state
as a percentage.
Outcome #3: Target Youths remain safe.
Performance Period: Contractor performance for this outcome is determined annually but measured quarterly
throughout the contract period.
Indicator: Percentage of families for whom a Primary Caregiver is not a designated perpetrator for an incident of
child abuse or neglect occurring while receiving services from the STAR Program
Target: 100%
Purpose: To evaluate the Contractor’s success in keeping children in STAR Program families safe
Data Sources: IMPACT and STAR Database
Methodology: The numerator is the total number of unduplicated families served in which the Primary Caregiver
in the STAR database is matched to a designated perpetrator as indicated in IMPACT, if the incident occurred
during the contract period and while the family was receiving STAR Program services. The denominator is the
total number of unduplicated families served in the Contractor’s STAR Program for the contract period. Divide the
numerator by the denominator, subtract this number from one, multiply by 100 and state as a percentage.
Definitions
Absolute Increase – A documented increase in the score for a subscale in the Post-Service Protective Factors
Survey Questionnaires relative to the score for the same subscale in the Pre-Service Protective Factors Survey
Questionnaires
Completed Protective Factors Survey Questionnaire – The Primary Caregiver responds to a minimum of 80% of
the questions in parts I-IV of the questionnaire administered both prior to the receipt of services and after services
to assess the level of family functioning/resiliency, social emotional support, concrete support, and nurturing and
attachment
Contract Period – The total length of this time frame is limited to all or part of the current fiscal year and shall not
exceed 12 months
Designated Perpetrator – As defined by 40 TAC (Texas Administrative Code) §700.512, “A person who has been
determined by a preponderance of the evidence to have been responsible for abuse or neglect of a child”
Eligible (To respond to the Post-Service Protective Factors Survey Questionnaire) – The Primary Caregiver must
have completed a Pre-Service Protective Factors Survey Questionnaire and:
Completed the prescribed STAR Program; or
Participated in the STAR Program for 180 days.
Eligible (To respond to the Pre-Service Protective Factors Survey Questionnaire) – The Primary Caregiver must
be newly registered into the STAR Program during the current contract period
Juvenile Delinquency – An act committed by a juvenile for which an adult could be prosecuted in a criminal court,
but when committed by a juvenile is within the jurisdiction of the juvenile court. Delinquent acts committed by
juveniles include crimes against persons, crimes against property, drug offenses, and crimes against public order
Post-Service Protective Factors Survey Questionnaire – A tool identical to the Pre-Service Protective Factors
Survey Questionnaire administered to the Primary Caregiver following the receipt of services and designed to
assess the level of family functioning/resiliency, social emotional support, concrete support, and nurturing and
attachment
Presenting Problem – The primary reason identified by the family or Target Youth for seeking services or by the
referral source as the basis for which services are needed
Pre-Service Protective Factors Survey Questionnaire (for Primary Caregivers) – A tool administered to the
Primary Caregiver prior to the receipt of services and designed to assess the level of family functioning/resiliency,
social emotional support, concrete support, and nurturing and attachment
45
ATTACHMENT C
Primary Caregiver - The caregiver or parent registered in the STAR Program, receiving a delivered service type,
and entered into the STAR database as the principal caregiver of the Target Youth. This person does not have to
be a guardian or head of household
Protective Factors – Personal characteristics or environmental conditions that interact with risk factors to reduce
the likelihood of problem behaviors
Subscale – Groups of questions on the Protective Factor Survey Questionnaire for Primary Caregivers indicative
of one of four protective factors: Family Functioning/Resiliency, Social Emotional Support, Concrete Support, and
Nurturing and Attachment
Target Youth – A youth age 0-17 years who is determined by the Contractor to be at risk of juvenile delinquency
and/or child maltreatment and whose behavior or safety, as applicable, is to be measurably improved by the
program
Unduplicated Target Youth – Any individual Target Youth receiving at least one service is only counted one time
during the contract period
Unduplicated Family – A Family in which a Primary Caregiver receiving at least one service is only counted one
time during the contract period
46
ATTACHMENT D
STAR FY13 - Quarterly
On-going Monitoring & Database Reports
Contractor: Enter Agency Name
Contract Number:
Months of Service:
Program: STAR
Percent of Contract Year Passed:
Contractor is required to submit the downloaded STAR database reports that reflect all performance
measures and a corrective action plan to DFPS no later than 30 days following the month of the
ending quarter (e.g. March 31*, June 30* or December 31*)for each performance measure that is off
track.
Based on reports from the Prevention and Early Intervention Services (STAR) database on
,
your organization is on track or not meeting the following performance measures. Please complete
the information below and return it to your contract manager no later than
.
* Or next business day if the due date falls on Saturday or Sunday.
Output Measures
Measure
Target
Contractor is On Track or Off Track
Output #1: The expected average number of Target Youths
are served monthly.
Output #2: The expected number of Target Youths are
served during the contract period.
Output #3: Pre-Service and Post-Service Protection Factors
Survey Questionnaires are completed by the Primary
Caregivers served.
1st
Quarter
Y/N
2nd
Quarter
Y/N
3rd
Quarter
Y/N
1st
Quarter
Y/N
2nd
Quarter
Y/N
3rd
Quarter
Y/N
60%
Outcome Measures
Measure
Target
Contractor is On Track or Off Track
Outcome #1: An absolute increase in the score for a
minimum of one protective factor is reported by unduplicated
families served.
Outcome #2: Target Youths will not engage in delinquent
behavior
Outcome #3: Target Youths will remain safe
1
95%
100%
_____________________________________
_____________
Signature of STAR Program Director/Administrator
Date
________________________________________
Signature of STAR Contract Manager
47
_______________
Date
ATTACHMENT E
STAR FY13 - Quarterly
Corrective Action Plan
Contractor is required to submit a Corrective Action Plan that reflects all performance measures not
on track to DFPS no later than 15 days after the end of the first, second and third quarters for
each performance measure that is off track. The Corrective Action Plan should be submitted with the
contractor Quarterly On-going Monitoring Report.
Output Measures
Output #1: The expected average number of Target Youths are served monthly.
Explanation of Variance: (Provide an explanation the first month or update for subsequent months, if applicable.)
Corrective Action Plan: (Provide an action plan the first month or update on actions taken for subsequent months.)
What actions will be taken to try and get this performance measure back on track?
Explain the timeline for implementation of actions described above.
Describe which staff will be responsible for implementation and oversight of the actions described above.
Output #2: The expected number of Target Youths are served during the contract period.
Explanation of Variance: (Provide an explanation the first month or update for subsequent months, if applicable.)
Corrective Action Plan: (Provide an action plan the first month or update on actions taken for subsequent months.)
What actions will be taken to try and get this performance measure back on track?
Explain the timeline for implementation of actions described above.
Describe which staff will be responsible for implementation and oversight of the actions described above.
Output #3: Pre-Service and Post-Service Protective Factors Survey Questionnaires are
completed by the Primary Caregivers served.
Explanation of Variance: (Provide an explanation the first month or update for subsequent months, if applicable.)
48
ATTACHMENT E
Corrective Action Plan: (Provide an action plan the first month or update on actions taken for subsequent months.)
What actions will be taken to try and get this performance measure back on track?
Explain the timeline for implementation of actions described above.
Describe which staff will be responsible for implementation and oversight of the actions described above.
Outcome Measures
Outcome #1: An absolute increase in the score for a minimum of one protective factor is
reported by unduplicated families served.
Explanation of Variance: (Provide an explanation the first month or update for subsequent months, if applicable.)
Corrective Action Plan: (Provide an action plan the first month or update on actions taken for subsequent months.)
What actions will be taken to try and get this performance measure back on track?
Explain the timeline for implementation of actions described above.
Describe which staff will be responsible for implementation and oversight of the actions described above.
Outcome #2: Target Youths will not engage in delinquent behavior.
Explanation of Variance: (Provide an explanation the first month or update for subsequent months, if applicable.)
Corrective Action Plan: (Provide an action plan the first month or update on actions taken for subsequent months.)
What actions will be taken to try and get this performance measure back on track?
Explain the timeline for implementation of actions described above.
Describe which staff will be responsible for implementation and oversight of the actions described above.
49
ATTACHMENT E
Outcome #3: Target Youths will remain safe.
Explanation of Variance: (Provide an explanation the first month or update for subsequent months, if applicable.)
Corrective Action Plan: (Provide an action plan the first month or update on actions taken for subsequent months.)
What actions will be taken to try and get this performance measure back on track?
Explain the timeline for implementation of actions described above.
Describe which staff will be responsible for implementation and oversight of the actions described above.
50
Form 9466 Rev 8/09
Prevention and Early Intervention Protective Factors Survey for Caregivers
PROGRAM STAFF USE ONLY
PRE TEST

POST TEST 
PEIS Client ID#
Caregiver First Name
Caregiver Last Name:
Caregiver DOB:
Today's Date:
Is this family member an expectant parent with no other children in the home?
Yes 
No 
Has this family member completed the program?
Yes 
No 
Thank you for taking the time to fill out this survey! The information will be used to evaluate the program. For each of
the questions, please answer in your own opinion or experience instead of trying to answer for other members of your
family. Please answer honestly. There are no right or wrong answers.
If you have any questions about one of the statements or the answer scale, ask one of the program staff. Please do not
skip a question.
Part I. Please circle the number that describes how often the statements are true for you or your family. The numbers
represent a scale from 1 to 7 where each of the numbers represents a different amount of time. For example, the number 4
means that the statement is true about half the time.
Never
Very
Rarely
Rarely
About Half
Very
Frequently
Always
the Time
Frequently
1. In my family, we talk about problems.
1
2
3
4
5
6
7
2. When we argue, my family listens to “both sides of the story.”
1
2
3
4
5
6
7
3. In my family, we take time to listen to each other.
1
2
3
4
5
6
7
4. My family pulls together when things are stressful.
1
2
3
4
5
6
7
5. My family is able to solve our problems.
1
2
3
4
5
6
7
Part II. Please circle the number that best describes how much you agree or disagree with the statement.
Strongly
Disagree
Mostly
Disagree
Slightly
Disagree
Neutral
Slightly
Agree
Mostly
Agree
Strongly
Agree
6. I have others who will listen when I need to talk about my
problems.
1
2
3
4
5
6
7
7. When I am lonely, there are several people I can talk to.
1
2
3
4
5
6
7
8. I would have no idea where to turn if my family needed food or
housing.
1
2
3
4
5
6
7
9. I wouldn’t know where to go for help if I had trouble making ends
meet.
1
2
3
4
5
6
7
10. If there is a crisis, I have others I can talk to.
1
2
3
4
5
6
7
11. If I needed help finding a job, I wouldn’t know where to go for
help.
1
2
3
4
5
6
7
Page 1 of 2
This survey was developed by the FRIENDS National Resource Center for Community-Based Child Abuse Prevention in partnership
with the University of Kansas Institute for Educational Research & Public Service through funding provided by the US Department of
Health and Human Services.
Form 9466 Rev 8/09
Prevention and Early Intervention Protective Factor Survey for Caregivers
Part III. This part of the survey asks about parenting and your relationship with your child. For this section, please focus on
the child that you hope will benefit most from your participation in our services.
Please write the child’s age or date of birth and then answer questions with this child in mind.
Child’s Age ______________ or
DOB _____/_____/_____
If you are expecting your first baby and there are no more children in your home, STOP here.
Strongly
Disagree
Mostly
Disagree
Slightly
Neutral
Disagree
Slightly
Agree
Mostly
Agree
Strongly
Agree
12. There are many times when I don’t know what to do as a parent.
1
2
3
4
5
6
7
13. I know how to help my child learn.
1
2
3
4
5
6
7
14. My child misbehaves just to upset me.
1
2
3
4
5
6
7
Never
Very
Rarely
Rarely
15. I praise my child when he/she behaves well.
1
2
3
4
5
6
7
16. When I discipline my child, I lose control.
1
2
3
4
5
6
7
17. I am happy being with my child.
1
2
3
4
5
6
7
18. My child and I are very close to each other.
1
2
3
4
5
6
7
19. I am able to soothe my child when he/she is upset.
1
2
3
4
5
6
7
20. I spend time with my child doing what he/she likes to do.
1
2
3
4
5
6
7
Part IV. Please tell us how often each of the following happens in your family.
About
Very
Always
Half the Frequently
Frequently
Time
Page 2 of 2
This survey was developed by the FRIENDS National Resource Center for Community-Based Child Abuse Prevention in partnership
with the University of Kansas Institute for Educational Research & Public Service through funding provided by the US Department of
Health and Human Services.
Form 9466 Rev 8/09
Prevención e Intervención Temprana - Cuestionario para el cuidador
sobre factores de protección
PROGRAM STAFF USE ONLY
PRE TEST

POST TEST 
PEIS Client ID#
Caregiver First Name
Caregiver Last Name:
Caregiver DOB:
Today's Date:
Is this family member an expectant parent with no other children in the home?
Yes 
No 
Has this family member completed the program?
Yes 
No 
Gracias por tomarse el tiempo para completar este cuestionario. La información se usará para evaluar el programa. Por
favor, conteste cada pregunta según su propia opinión o experiencia en vez de tratar de contestar por otros miembros de la
familia. Favor de contestar francamente. No hay respuestas correctas ni incorrectas.
Si tiene alguna pregunta sobre una de las afirmaciones o sobre la escala de respuestas, hable con el personal del
programa. Por favor, no se salte ninguna pregunta.
Parte I. Por favor, encierre en un círculo el número que mejor describa con qué frecuencia la afirmación es cierta para
usted o su familia. Los números representan una escala del 1 al 7. Cada número representa una frecuencia distinta. El
número 4 significa que la afirmación es cierta más o menos la mitad de las veces.
Nunca
Muy pocas
veces
Pocas
veces
La mitad
de las
veces
Frecuentemente
Muy
frecuentemente
Siempre
1
2
3
4
5
6
7
2. Cuando discutimos, mi familia escucha
"ambos lados de la historia".
1
2
3
4
5
6
7
3. En mi familia, tomamos el tiempo para
escucharnos.
1
2
3
4
5
6
7
4. Mi familia está más unida cuando pasan
cosas estresantes.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1. En mi familia, platicamos sobre los
problemas.
5. Mi familia puede resolver sus propios
problemas.
Parte II. Por favor, encierre en un círculo el número que mejor describa su acuerdo o desacuerdo con la afirmación.
Muy en
En
desacuerdo desacuerdo
en gran parte
Un poco en
desacuerdo
Neutral
Un poco
de
acuerdo
De acuerdo
en gran
parte
Muy de
acuerdo
6. Cuando necesito hablar de mis problemas,
tengo quien me escuche.
1
2
3
4
5
6
7
7. Cuando me siento solo, hay varias personas
con quienes puedo hablar.
1
2
3
4
5
6
7
1
El FRIENDS National Resource Center for Community-Based Child Abuse Prevention en asociación con el Institute for Educational Research & Public
Service de la University of Kansas diseñó este cuestionario con fondos recibidos del Departamento de Salud y Servicios Humanos de EE. UU..
Form 9466 Rev 8/09
Muy en
En
desacuerdo desacuerdo
en gran parte
Un poco en
desacuerdo
Neutral
Un poco
de
acuerdo
De acuerdo
en gran
parte
Muy de
acuerdo
8. Si mi familia llegara a necesitar comida o
vivienda, no tendría idea adónde acudir.
1
2
3
4
5
6
7
9. Si tuviera problemas para hacer alcanzar el
dinero, no sabría dónde buscar ayuda.
1
2
3
4
5
6
7
10. Si hay una crisis, tengo con quien hablar.
1
2
3
4
5
6
7
11. Si necesito ayuda para encontrar trabajo, no
sabría adónde ir para que me ayudaran.
1
2
3
4
5
6
7
Parte III. Esta parte del cuestionario le pregunta sobre el ser buenos padres y su relación con su hijo. Para esta
sección, por favor, concéntrese en el niño que usted espera se beneficie más de su participación en nuestros servicios.
Por favor, escriba la edad o la fecha de nacimiento del niño y luego conteste las preguntas teniendo en cuenta a este
niño.
Edad del niño ______________
o
FDN _____/_____/_____
Si está esperando su primer bebé y en su hogar no vive ningún otro hijo, PARE aquí.
Muy en
desacuerdo
En
desacuerdo
en gran
parte
Un poco en
desacuerdo
Neutral
Un poco
de
acuerdo
De acuerdo
en gran
parte
Muy de
acuerdo
12. A veces no sé que hacer como padre.
1
2
3
4
5
6
7
13. Sé cómo ayudar a mi hijo a aprender.
1
2
3
4
5
6
7
14. Mi hijo se porta mal para hacerme enojar.
1
2
3
4
5
6
7
Parte IV. Por favor, díganos con qué frecuencia ocurren las siguientes cosas en su familia.
Nunca
Muy pocas
veces
Pocas
veces
La mitad
de las
veces
Frecuentemente
Muy
frecuentemente
Siempre
1
2
3
4
5
6
7
16. Cuando disciplino a mi hijo, pierdo el
control.
1
2
3
4
5
6
7
17. Estoy feliz cuando estoy con mi hijo.
1
2
3
4
5
6
7
15. Elogio a mi hijo por portarse bien.
2
El FRIENDS National Resource Center for Community-Based Child Abuse Prevention en asociación con el Institute for Educational Research & Public
Service de la University of Kansas diseñó este cuestionario con fondos recibidos del Departamento de Salud y Servicios Humanos de EE. UU..
Form 9466 Rev 8/09
Prevención e Intervención Temprana - Cuestionario para el cuidador
sobre factores de protección
Nunca
Muy pocas
veces
Pocas
veces
La mitad
de las
veces
Frecuentemente
Muy
frecuentemente
Siempre
18. Mi hijo y yo tenemos una relación muy
estrecha.
1
2
3
4
5
6
7
19. Puedo consolar a mi hijo cuando está
molesto.
1
2
3
4
5
6
7
20. Paso tiempo con mi hijo haciendo las cosas
que le gustan a él.
1
2
3
4
5
6
7
3
El FRIENDS National Resource Center for Community-Based Child Abuse Prevention en asociación con el Institute for Educational Research & Public
Service de la University of Kansas diseñó este cuestionario con fondos recibidos del Departamento de Salud y Servicios Humanos de EE. UU..
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