Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Supported Employment

Date:______________ Rater(s): ________________________________________

Program Name: ______________________________________________________

Address: ___________________________________________________________

Contact Person: (Title: )_______________________________________________

Phone: _________________________: Fax: ______________________________

E-mail: _____________________________________________________________

Sources Used:

____ Chart review	____ Agency brochure review
____ Team meeting observation	____ Supervision observation
____ Interview with Program Director/Coordinator
____ Interview with practitioners	____ Interview with clients
____ Interview with supervisors
____ Interview with rehabilitation service providers
____ Interview with ______________________
____ Interview with ______________________
# of EBP Practitioners: _________
# of active clients served by EBP: _________
# of clients served by EBP in preceding year: _______
# of charts reviewed _______
Date program was started: _______