Appendix 2: Concept Statement Template for Service Providers

Descriptive Information about the Organization

Name, address, contacts, programs and services offered:

Specific Program to which this Concept Statement applies:

Mandate and Vision of Program:

Description of Program:

Include #of clients, gender, ages, physical infrastructure, staffing ratio, #of staff, additional clinical resources, etc.

Youth Profiles:

Define the profiles of young people who can best be served in this program; provide specific information about developmental and clinical profile, family constellation and need for participation, externalizing behaviours


Describe who the program cannot serve well. List excluding factors (eg: fire setting, physical aggression, sexual offending)

Theoretical framework for service delivery:

What informs the design of this program? (eg: attachment theory, trauma-informed care, resilience, strength-based, narrative, etc.) Explain how this relates to the Youth profile the program seeks to serve.

Use of Evidence-Based Practice:

List all evidence-based practices and clearinghouse references; explain how these relate to the youth profile the program seeks to serve

Use of Best Practices:

List all approaches and interventions that are considered best practices, and provide rationale for why these are considered best practices and references.

Youth Voice and Participation:

Describe all aspects of young people’s participation in the governance, design, operation and individual-level case planning in this program. Provide a list of measurable indicators for these initiatives.

Staff Qualifications:

List all staff (FT/PT/Casual & One to One), their pre-service qualifications and their training and PD records for the past five years; explain how qualifications and training records relate to the client profiles the program seeks to serve and to the program and client-level objectives defined below.


Describe the supervision process for all front line staff; indicate the supervision model in use, and why this is the appropriate model in relation to the goals and objectives of the program and the types of young people served. Also include the qualifications and training of the supervisor.

Program Objectives – program-level outputs and outcomes:

Describe what this program seeks to accomplish; what difference will it make in the lives of the young people; identify measurable indicators related to each program-level output and outcome.

Program Objectives – client-level outputs and outcomes:

Describe what change is expected in clients; what areas of young person’s life will be impacted in what ways, and what indicators are used to measure this change.

Progress Data from the past 12 months:

Listing each of the indicators identified for this program, provide data related to program-level and client-level outputs and outcomes.

Analysis of Activity over the past 12 months:

Explain the data above in relation to what has worked and what has not worked. Provide clear explanations for any circumstances where the data does not indicate positive movement.

Children’s Rights:

Describe how young people are informed of their rights and how rights reinforced on an ongoing basis. Please attach any material used in helping young people understand their rights.

Behaviour Management/Intervention:

Describe the approach to behavior management within the program. Include descriptions of point and level systems, token economies and frequently used consequences (withdrawal of privileges, early bed times, grounding).

Crisis Management and Physical Intervention:

Describe the approach to crisis prevention/intervention. Include policies and practices related to the use of physical interventions, debriefing and restorative practices.

Community Involvement:

Describe all community partnerships that are directly related to this program and provide a list of community involvements of every young person over the past 12 months. Provide a list of measurable indicators for these initiatives.

Unique Identity:

Describe all initiatives related to support and special provisions in the context of gender identity, racial identity, cultural competence, vegetarian/ vegan lifestyles and other. Provide a list of measurable indicators for these initiatives.


Describes all initiatives and supports related to school-based performance and everyday life-based learning. Provide a list of measurable indicators for these initiatives.