Getting An Agency License

In order to offer the Survivor Moms' Companion through your agency, an authorized agency administrator must obtain a license from The Sidran Institute. Fill out the form below and click Submit. The Sidran Institute will use your email address to send you license purchasing instructions and your agency code.

Make a record of your agency code after you receive it. Your tutors and supervisors will need this to record information regarding the clients they tutor under your supervision.



  • Agency Administration Commitments

    As the responsible administrator of an agency or organization delivering the SMC intervention, I commit to the following statements:

    Supervisors
    1. We have engaged a supervisor who will:
    • Lead implementation of the SMC and serve as on-going liaison to the SMC staff. The supervision role includes:
      • Selecting, overseeing training process, monitoring fidelity, remediating, and arranging re-certification of tutors
      • Conducting an agency-wide in-service training about traumatic stress and the SMC intervention
      • Providing license-related forms and (for Early Adopters only) anonymized clinical documentation to the SMC staff
    • Provide clinical supervision, including case consultation, working through challenges, addressing vicarious trauma, or other needs, consistent with norms in behavioral health service settings. NOTE: If the selected supervisor is not an experienced, licensed clinician, then we also have engaged such a person to provide the clinical supervision.
    2. We assure you that the supervisor has adequate capacity and authority to fulfill these roles, as outlined in the supervisor statement of commitment (appended).
    3. We will facilitate an all-hands, agency-level training to advance our services toward being fully trauma-informed. This is an in-service Trauma Informed Care (TIC) education program, developed by SMC and presented by the supervisor.
    4. We have compiled, and will assist the supervisor to maintain, a list of referral resources appropriate to trauma-informed care in the perinatal period, including:
    • Intimate partner violence services
    • Substance abuse services
    • Specialist mental health services (i.e., psychiatrist, psychotherapist)
    • Child welfare services
    • Emergency care where psychiatric concerns can be addressed
    5. We understand that the supervisor will audit fidelity of all tutors by periodically requesting fidelity checklists from tutor and client for the same session (i.e., “mirror image reports”). The supervisor also will periodically review a case file to verify that safety was monitored and referrals were appropriate. The supervisor will document tutor performance as:
    • True to the curriculum (>80% on the SMC fidelity guide/checklist)
    • Of high quality in terms of the tutor-client relationship (respect and rapport, attaining active participation from the mom)
    • Safe, with appropriate referral
    6. We understand that, at the time of license renewal at the end of Year 2, the supervisor will also request and evaluate at least one case study by each tutor (on the form provided) documenting knowledge of SMC’s use. The supervisor will recommend for or against re-certification of the tutor based on fidelity, quality, and safety.

    Tutors
    1. We select, train, and supervise only tutors who are certified or licensed professionals and paraprofessionals (nurses, social workers, psychologists, midwives, physicians, doulas, health educators, community outreach workers, or other experienced staff). If, in our state, paraprofessional health workers are not certified, we assure you that they are trained and experienced in their role. Furthermore, we understand that the SMC is not to be used as a peer-to-peer intervention.
    2. We assure you that the tutors have adequate capacity to fulfill their role, including the capacity to set tutoring appointments and facilitate referrals.
    3. We understand that tutor fidelity to the manual is the best predictor of effectiveness for manualized programs like the SMC (Bellg AJ et al., 2004, Moore GF et al., 2015)*, so tutors will:
    • Use the “Each and Every Time” fidelity guide and fidelity checklist
    • Use the SMC tools for assessment, monitoring, and referral tracking
    • Make use of clinical supervision for challenging or unique cases
    • Strive for a high-quality tutor-client relationship because helping clients feel supported while they are learning skills is an essential intervention component
    • Accept remediation via further training or additional supervision if needed
    Documentation
    1. We support completion and storage of SMC (electronic and/or paper) documentation as follows:
    • License-related documents, including forms pertaining to agency-level training, tutor training, fidelity monitoring, remediation, and re-certification, as well as documentation of availability and utilization of clinical supervision.
    • Clinical documents, including anonymous Starting Assessment, Client Folio notes, and Ending Assessment forms for each participating survivor mom.
    2. We acknowledge that conveying the license-related reports to SMC staff is required to maintain our SMC end-user license. We agree to have supervisors convey the anonymous clinical documentation forms to the SMC staff for research purposes.
    3. We understand that, at the time of license renewal, SMC staff will review the license-related documentation and discuss any impediments with the supervisor.

    Licensing
    1. We have read the list of commitments required of tutors and supervisors and agree to their scopes of work.
    2. We are aware that we can contact the SMC staff to get information, technical assistance, or consultation as part of the agency’s end-user license agreement.
    3. We are aware that SMC tutoring and supervision occurs only in the setting of an agency or organization holding an end-user license agreement with the Sidran Traumatic Stress Institute and that the SMC curriculum and materials may not be used outside this context or at variance from the license agreement except by express written permission.
    4. We have read and e-signed the Terms of Use, Privacy Policy, and End User License Agreements on the SMC website.

    (If some aspect of these Commitments is impossible in your setting, please contact us to discuss how we might accommodate your needs.)
    Email: maryanne.reilly@survivormoms.org
    Phone: 410-825- 8888, EXT. 105

    *References regarding fidelity:
    Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, et al. Enhancing treatment fidelity in health behavior change studies: Best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23(5):443–51. doi: 10.1037/0278-6133.23.5.443

    Moore GF, Audrey S, Barker M, et al. Process evaluation of complex interventions: Medical Research Council guidance. The BMJ. 2015;350:h1258. doi:10.1136/bmj.h1258.


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