Site Program Information Survey This important data helps us to know where CF! is being provided and gives us valuable information about families served. Be sure to keep a copy for your own records. Date Agency Contact Name Title Email Phone Number Address City State Year Started with CFAP Curriculum Used Online 2021 2019 2013 Older than 2013 iCelebrando Familias! Wellbriety Partnership Celebrating Families! Adolescent Program Partner Agency Type (FTC/Preschool/Church/Treatment Cntr/Child Welfare/etc) Lead Contact Name/Title Lead Contact Email List any other community support/partnership (Meals provided by faith community or grocery store donation, etc) Program Information Program Start Date Program Completion Date Day Of Week And Time Number of Sessions Completed (if not 16 pls note what was removed) Number of Families Recruited Number of Families Enrolled/Started Number of Families Who Dropped Out/Unenrolled[Please note reason(s)] Number of Families Completed Adult Participants By Ethnicity (pls note count): Asian African American/Black/Brown Caucasian/White Hispanic/Latin Tribal Families Other (pls specify) Number Of: Grandparents Foster Parents (should be a separate group from parents) Other Caregivers (Please Specify Relationship) 0 - 3 Young Children (4-6) Children (7-10) Pre-Teens (11-13) Teens in Recovery Teens/Young Adults (14-18) Incentives: Do you provide Incentives? Yes/No For those who provide Incentives: Do you provide incentives in every session? If Family Treatment Court, is attendance is mandated? Per session? Cash/Vouchers/Gifts - Total Dollar Value/Family Upon Completion? (can participate in both!) Cash/Vouchers/Gifts - Total Dollar Value/Family Provided Book/Activity Check Out for families to take books/games/art supplies home and return Evaluation: Used CF! Provided Tools Used Organizational Tools Sessions Collected Method Collected? (Took Home, Read To Them In Group, Read Themselves) Number Of Referrals From : Child Protective Services Court Family Services SUD Referrals Other Number Of Referrals To: Child Protective Services Court Family Services SUD Treatment Other Transportation Provided: Yes/No Child Care: Providing 0-3? Who Provided? Number Of Staff Volunteer Or Paid? Number Of Children & Ages Please feel free to include your outcome report/annual report with this form, or when available. Greatest Strength of Your Program Greatest Barrier(s) to Program Success Any Comments/Quotes from Participants You Wish to Share Any Comments from Group Leaders Providing the Program You Wish to Share Did You Provide Hybrid Online Sessions – Throughout the Program or as Needed Due to Weather, Traffic Challenges, etc.? If So, How Was That Experience? Family Recovery Support Post Program (indicate if you provide or elsewhere in the community) Any Unusual Challenges In Implementing This Program Additional Comments/Insights/Suggestions To Improve Implementation For Your Agency A summary of your submission will be provided for your records. Contact NACoA's Office Administrator with any questions: nacoa@nacoa.org. SUBMIT
