retention

Review FORM

Clinician Name(Required)

Clinician Email(Required)

Retention Review Team Members Present(Required)

Stacy Blassingame

Morgan Dietz

Cortney Dollens

Nicole Neace

Ryan Thomas Neace

Emily Williams

Reviewer Completing Form, Position(Required)

Current Clinical Supervisor Name(Required)

Current Clinical Supervisor Email(Required)

Add previous supervisor email?(Required)

Yes

Previous Supervisor Email (will also receive copy of RRF)(Required)

Date of Review(Required)

MM slash DD slash YYYY

(Today's Date)

6-Month Review Period End Date(Required)

MM slash DD slash YYYY

example: 12/31/21

Constructive Appraisal Section

Clinician Assessment

What has "gone right" over the past 6 months for you clinically and what has been working well? What has "gone wrong" over the past 6 months for you clinically and what has not been working well?(Required)

Clinician appraisal of how strongly negative clinical issues/events mentioned in previous question were correlated to under-10 session drop-outs?(Required)

What has "gone right" over the past 6 months within our environment at Change, Inc., to include administrative/logistical/team-related items, and what stands out to you as having been effective, supportive, positively impactful, etc.? Also, what has "gone wrong" over the past 6 months within our environment at Change, Inc., to include administrative/logistical/team-related items, and what stands out to you as having been less than effective, less than supportive, negatively impactful, etc.?(Required)

Clinician appraisal of how strongly negative environmental issues/events mentioned in previous question were correlated to under-10 session drop-outs?(Required)

What has "gone right" over the past 6 months for you more interpersonally-professionally (the intersection of your interpersonal functioning with your professional functioning), and was there anything you can point to from your outside life that is improving your functioning overall (and therefore as a clinician)? Also, what has "gone wrong" over the past 6 months for you interpersonally-professionally (the intersection of your interpersonal functioning with your professional functioning), and was there anything you can point to from your outside life that is negatively impacting your functioning overall (and therefore as a clinician)?(Required)

Clinician appraisal of how strongly personal environmental issues/events mentioned in previous question were correlated to under-10 session drop-outs?(Required)

Retention Review Section

Past 6-Months Retention Rate(Required)

Please enter a number from 1 to 100.

MET 55%

Past 12-Months Retention Rate(Required)

Please enter a number from 1 to 100.

MET 55%

Quantitative Analysis

How many people have been referred to Clinician in last 6-months?(Required)

Please enter a number from 1 to 100.

How many people have been referred to Clinician in last 12-months?(Required)

Please enter a number from 1 to 100.

At that same rate of referral, how many referrals would have to be provided in order to maintain caseload over 3 years? (Auto-Calculates)(Required)

How many people have left therapy in last 12-months?(Required)

Please enter a number from 0 to 100.

4-sessions or less?(Required)

Please enter a number from 0 to 100.

5-9 sessions?(Required)

Please enter a number from 0 to 100.

Under 10 sessions (Auto-Calculates)?(Required)

Percentage of those who left in Under 10 Sessions in Past 12-months? (Auto-Calculates)(Required)

Number of clients attending less than required frequency?(Required)

Please enter a number from 0 to 100.

Qualitative Analysis

Of the clients who left in less than 10-sessions over the last 12 months, how many left without any notice at all (i.e., no termination, no phone call, no email -- just stopped coming)(Required)

Percentage of clients without notice out of total number of past 12-month drop-outs?(Required)

Did clinician follow-up with all clients?(Required)

If no, please explain.(Required)

Of the clients who left in less than 10-sessions over the last 12 months, how many left by emailing clinician or emailing/calling CLT and saying they were no longer coming?(Required)

Percentage of clients left by emailing/calling out of total number of past 12-month drop-outs who left in less than 10-sessions? (Required)(Required)

Of the clients who left in less than 10-sessions over the last 12 months, how many actually took part in a planned termination (including if brief)? i.e., how many talked with clinician about leaving during a session at least one time?(Required)

Percentage of clients planned termination out of total number of past 12-month drop-outs who left in less than 10-sessions? (Required)(Required)

Of the clients who left in less than 10-sessions over the last 12 months, how many were couples?(Required)

Percentage of couples out of total number of past 12-month drop-outs who left in less than 10-sessions? (Required)(Required)

Of the clients who left over the last 12 months, what themes emerge?(Required)

e.g., presenting problem, age, gender, sexual orientation, etc.

25% of those clients who left in Under 10 Sessions in Past 12-months for next question. (Auto-Calculates)(Required)

Of the clients who left over the last 12 months, consider at least 25% of those who left in under 10 sessions (as calculated immediately above). Go client by client and describe to what clinician attributes drop-out.(Required)

e.g., presenting problem, age, gender, sexual orientation, etc.

Clinician requested percentage (of total referrals) for drop-outs believed to be unavoidable (or essentially unavoidable). NOTE: 2/3 of CD/ACD/CEO must agree.

Please enter a number from 0 to 20.

Calculate actual number of clients for whom drop-outs were believed to be unavoidable (or essentially unavoidable) divided by total referrals to get percentage. (Max 20%)

6-month retention rate plus avoidable/essentially unavoidable drop-outs? (Auto-calculates)

12-month retention rate plus avoidable/essentially unavoidable drop-outs? (Auto-calculates)

Retention Review Team (RRT) Closing Assessment

To what degree does RRT's appraisal of client drop-outs concur with above clinician attributions (check one)?(Required)

Strongly Agree

Agree

Disagree

Strongly Disagree

Please explain concerns.(Required)

What are the clinician's clinical strengths and assets demonstrated during retention review or at-large? What are the clinician's clinical growth edges or struggle points as demonstrated during retention review or at-large?(Required)

Please list. 1. _______ 2. _______ (etc.)

Clinician openness to retention review (check one)(Required)

Very Open

Somewhat Open

Somewhat Closed

Very Closed

Please explain what RRT noticed.(Required)

RRT Recommendations or Requirements?

Recommendations

Requirements

Please note the following RRT requirements.(Required)

Please note the following RRT recommendations.(Required)