Amendment Number Subcontract No. 2019 FY19 Program Abstract SERVICE AGENCY SUBCONTRACTOR Agency Name: Street: City: County: Zip: Phone: Fax: E-mail: PRIMARY SERVICE SITE Program Name: Street: City: County: Zip: Phone: Fax: E-mail: Onsite Program Supervisor: PROGRAM MODEL Healthy Families Illinois Parents as Teachers Nurse Family Partnership HFI PROGRAMS Credentialing Status: Date of HFA Accreditation/PAT Endorsement:
FY19 Program Abstract DOULA HOME VISITING MODEL Indicate the number of visits each month in the staff columns to illustrate the program model of Doula Services. ENROLLED PARTICIPANT # Doula Visits # Combined Visits* Total suggested Doula visits # HV Visits Total # of Visits Total # suggested visits Prenatal Month 7** 2-4 3-5 Prenatal Month 8 3-5 4-6 Prenatal Month 9 3-5 4-6 Total Prenatal Visits 8-14 11-17 Postnatal Month 1 4-5 4-6 Postnatal Month 2** 2-3 3-5 Total Postnatal Visits 6-8 7-11 Total Visits to Participant 14-22 18-28 SHORT-TERM PARTICIPANT # Doula Visits # Combined Visits* Total suggested Doula visits # HV Visits Total # of Visits Total # suggested visits Prenatal Month 7** 2-4 3-5 Prenatal Month 8 3-5 4-6 Prenatal Month 9 3-5 4-6 Total Prenatal Visits 8-14 11-17 Postnatal Month 1 4-5 4-6 Postnatal Month 2** 2-3 3-5 Total Postnatal Visits 6-8 7-11 Total Visits to Participant 14-22 18-28 *Combined Visit refers to a single home visit where both a Doula and home visitor (for an enrolled participant) or Doula and a community partner (for a short-term participant) are present. **Programs may choose to have Doulas visit prior to the third trimester of pregnancy or after the baby turns three months old, but there are no contractual expectations for these visits.
Subcontract No. 2019- FY19 Program Abstract PARENT GROUP SERVICES – ONGOING PARENT GROUPS If not applicable to this program, please check Enter information for each ongoing group for which a Group Profile will be created in OunceNet. Note: “Cycle” refers to the number of times the same group is held for the same returning core of group members. Group Name and Staff (includes volunteers) # of Sessions Total Group Sessions # in Groups Enrolled # in Groups Short-term Meeting Day/Time Location* Meals Child Care Trans. Q1 Q2 Q3 Q4 Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Total # of Sessions Total # of Participants to be Served *** LOCATION CODES S= School-based C= Center-based O= Other facility, i.e., church, other agency Please list the name(s) of the core group curricula used: 1. 2. 3.
Subcontract No. 2019- FY19 Program Abstract PTS/HFI SITES – FAMILY ASSESSMENT SERVICES If not applicable to this program, please check Please indicate which model you are using to determine program eligibility: Kempe Family Stress Checklist One Step Eligibility Screening Programs using the Kempe Family Stress Checklist, please complete the following table: Name/Title % FTE in Agency % FTE FAW # Completed Assessments per Year % % % % % % % % % % Total (minimum of 192 assessments per year per 100% FTE) Programs using the One Step Eligibility Screening, please provide the number of screenings to be completed during the fiscal year: Subcontract No. 2019- FY19 Program Abstract CLINICAL/INFANT MENTAL HEALTH SERVICES If not applicable to this program, please check here Name/Title % FTE in Agency % FTE IMH % % % % Staff Consultation Modality (case staffing, individual staff consultation, training) Frequency