Policies and Prodedures

Trauma in job description/interview

  • Job descriptions include knowledge, skills and abilities to work with people affected by trauma
  • Job interviews include trauma content and questions about knowledge and skills related to trauma-informed practice

Training to promote general awareness

  • All staff at all levels receive basic foundational training and continued training (as appropriate) that furthers their understanding of trauma, including a basic understanding of the psychological, neurological, biological, relational and spiritual impact that trauma has on people
  • Staff members are released from their usual duties to attend training

Staff receive training on the following topics:

  • Links between mental health, substance use and trauma (and co-occurring disorders)
  • Cultural competency, including different cultural practices, beliefs, rituals, different cultural responses to trauma, and the importance of linking cultural safety and trauma-informed practice 
  • How gender influences the types of trauma experienced, and the individual and systemic responses to trauma
  • Communication and relationship skills, including nonconfrontational limit setting, “people first” language (e.g., people who are experiencing homelessness, reflective listening, skills, etc.)
  • Minimizing retraumatization, including psychoeducational framing, coping mechanisms, a cultural safety lens, de-escalation strategies, grounding and emotional modulation techniques
  • Vicarious trauma, how it manifests and ways to minimize its effects, including self-care, resiliency and personal/ professional boundaries
    • Understanding and being able to recognize fight, flight and freeze responses
    • Developing the capacity to be self-soothing and self-compassionate through various means (i.e., mindfulness-based stress reduction or other mindful practices)
    • Understanding and appreciating the mind/body/spirit connection
    • Suicide prevention

Staff receive training that promotes:

  • Awareness of trauma-specific services in the mental health system
  • Awareness of the range of specialized services outside of mental health and substance use systems that support people with trauma, such as anti-violence services, services for refugees and victims of torture, veterans’ services LGBTTQI * services, Aboriginal healing services, and gender specific support groups

Regular Supervision

  • All staff that work with trauma survivors have structured, strength-based supervision from someone who is trained in understanding trauma

Staff Meetings

  • Regular staff meetings include opportunities for knowledge exchange on working with trauma
  • Staff are encouraged to discuss ethical issues associated with defining personal and professional boundaries

Peer Support

  • Opportunities for peer support and consultation are regularly offered

Support for All Safety

  • Regular supervision is devoted, in part, to helping staff understand their own stress reactions
  • Self-care is encouraged among staff, and issues related to safety/self-care are addressed at staff meetings  trauma -informed care and practice
  • The organization regularly seeks input from staff about their safety, and/or assesses staff safety through other mechanisms, and makes improvements wherever possible
  • The organization provides appropriate supports to staff that have experienced vicarious trauma
  • The organization promotes a psychologically safe work environment for staff and volunteers

Universal Screening

  • The intake policy clearly states the purpose of screening for history of trauma, and how that will be used to inform service planning as it applies to all consumers, regardless of how they enter the system (“which door”)
  • The screening and assessment process is fully discussed with C/P/R, and C/P/R choice and control of what will be disclosed is emphasized throughout
  • The potential for retraumatization during screening and assessment is formally acknowledged by the organization, and policies are in place to minimize the potential for retraumatization
  • The screening and assessment protocol is informed by currently available academic and practice evidence about being trauma-informed

Location for intake assessment

  • Intake is conducted in a private, confidential space
  • Appropriate interpreters are provided as needed (e.g., not a family member or an interpreter untrained in trauma)


  • Screening is followed-up (as appropriate) with the opportunity for consumers to become aware of how trauma is connected to mental health and substance use concerns, to learn coping skills, and to disclose their history of trauma at their own pace
  • Supports are in place for consumers after assessment if trauma history is discussed

Policies and Procedures Criteria

Your organization ensures that all current policies and protocols are not hurtful or harmful to trauma survivors, are respectful, and promote safety, trust and flexibility.

Consumer Choice

  • C/P/Rs are given full choices in what services they receive, and are allowed to make decisions about their level of participation and the pacing of these services
  • C/P/Rs are encouraged to make informed choices through the provision of educational materials, and the discussion about potential services available to them, as well as the benefits, limitations and objectives of each Survivor Involvement
  • People who have been affected by trauma are involved in the creation and evaluation of policies and protocols
  • C/P/Rs are able to suggest improvements in ways that are confidential and anonymous and/or public and recognized

Cultural Competency

  • All policies respect culture, gender, race, ethnicity, sexual orientation and physical ability

Privacy and Confidentiality

  • All staff and consumers are aware of what is involved in the informed consent process, including the extent and limits of confidentiality, what is included in the records, and where the records are kept 
  • Established processes are in place that support  consumer awareness and the understanding of informed consent

Safety and Crisis Planning

  • All C/P/Rs have individualized safety plans that are fully integrated into the programs’ activities. Include a list of stressors, specific helpful strategies, specific non-helpful strategies, a strategy for coping with suicidal thoughts, and a list of persons that they feel safe around
  • A service policy is in place that informs how individual safety plans are used in a crisis. This policy should be reviewed when necessary

Avoiding Re-Traumatisation

  • Policies or procedures are in place to minimize the possibility of retraumatization Supportive/Emotionally Safe Program
  • C/P/R rights are posted in visible places
  • The program avoids involuntary or potentially coercive aspects of treatment (e.g., involuntary medication, seclusion, restraints)

Physical Environment

  • The space around the program building is safe (e.g., parking lot and sidewalks are well lit, directions to the program are clear)
  • The physical environment is attuned to safety (e.g., calming and comfortable)


  • Based on intake assessments, C/P/Rs are referred to accessible and affordable trauma-specific services as necessary
  • C/P/Rs are engaged in the decision about any referral to external programs, if appropriate, and are informed about what to expect from the referral agency
  • C/P/Rs are supported throughout the transition to external services

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