REGISTRATION FORM

CISM: Individual Crisis Intervention and Peer Support (PN65)

October 13-14, 2008

(Please type or print; photocopy for additional registrants; telephone registrations cannot be accepted.)

 

SS#: (Last five digits only):  __ - __ __ __ __

 

Name______________________________________

 

Agency_____________________________________

 

Address ____________________________________

 

City ___________________State____ Zip _________

 

Phone ______________________________________

 

Email_______________________________________

 

County______________________________________

 

Specialty/Degree(s)___________________________

 

Are you a WPIC employee?    □Yes □ No

 

For Continuing Education Purposes,

please check if you are:

□    NBCC Counselor (NBCC #_________)

□    Social Worker/LPC/LMFT

□    Nurse

□    Psychologist

□    Educator (Act 48)

□    EMS

□    CPRP

□    CAC/CCDP

 

Tuition:  $________           Method of Payment:

 

□ UPMC Account Transfer    □American Express

 

□ MasterCard   □ Discover   □Visa   □ Check #______

                                                                                              (Payable to OERP/WPIC)

To be completed by credit card users only:

Card Number _______________________________

 

Expiration Date: __________Security Code: _______

 

Signature: __________________________________

 

To be completed for UPMC account transfers:

Account #__________________________________

 

Administrator’s Name_________________________

 

Administrator’s Signature______________________ 

 

CISM: Individual Crisis Intervention and Peer Support (PN65)

October 13-14, 2008

 

OVERVIEW:

Crisis intervention is NOT psychotherapy, rather it is a specialized acute emergency mental health intervention which requires specialized training.  As physical first-aid is to surgery, crisis intervention is to psychotherapy. Thus, crisis intervention is sometimes called "emotional first-aid."  Crisis interventions are typically done individually (one-on-one) or in groups. This program is designed to teach participants the fundamentals of, and a specific protocol for, individual intervention.

 

EDUCATIONAL OBJECTIVES:

At the conclusion of this program, participants should be able to:

  • Explain the concept of CISM as a comprehensive crisis intervention program
  • Understand the role of the individual crisis intervention in the comprehensive CISM program
  • Utilize terms and concepts relevant to the study of crisis, traumatic stress and crisis intervention
  • Differentiate utilities of selected crisis communication techniques
  • Demonstrate selected crisis communication techniques
  • List psychological reactions to crisis and trauma
  • Use SAFER protocol for individual crisis intervention and it's role in comprehensive CISM
  • Demonstrate the use of SAFER protocol for individual crisis intervention
  • Review common problems encountered while working with individuals in crisis

 

WHO SHOULD ATTEND:

The audience for this class includes emergency services, military, and business/industrial peer support personnel without formal training in mental health, as well as mental health professionals who desire to increase their knowledge of individual (one-on-one) crisis intervention techniques.

PRESENTERS:

 

Robert Fonte, RN, MEd

ICISF Trainer

Program Director, Crisis Training Institute

Office of Education and Regional Programming

Western Psychiatric Institute and Clinic

 

Jeffrey D. Magill, BA

ICISF Trainer

Crisis and Disaster Training Specialist

Office of Education and Regional Programming

Western Psychiatric Institute and Clinic

 

TUITION:

General …….................................................$200.00

First Responders, Comprehensive Crisis Management Trainers and UPMC Presbyterian Shadyside staff …………………………………………………..$175.00

 

Tuition includes all registration and workshop materials; continental breakfast, lunch and refreshments; in addition to continuing education credits. Full tuition must accompany the registration form.  Please make checks out to WPIC/OERP.  A $15.00 administrative fee will be deducted from any cancellation received less than two weeks before the session.  No refunds can be issued once the program has begun.    Please mail completed registration form and payment to:

ATTN: Kyessa L. Brian           Telephone: 412-802-6905

WPIC/OERP                              Fax: 412-802-6910

4601 Baum Bldg, First Floor    Email: briankl@upmc.edu

3811 O’Hara Street                 www.wpic.pitt.edu/oerp

 

Directions:

UPMC SHADYSIDE

Herberman Conference Center, Room 202C

5230 Centre Avenue

Pittsburgh, PA 15232

(412) 623-2121       Main Number

From the East
Take the Parkway East (Route 376) to Exit 7 (Edgewood/Swissvale). At the end of the exit ramp, turn right onto South Braddock Avenue. Go approximately two miles and turn left onto Penn Avenue. At the intersection of Penn and Fifth Avenues, turn left onto Fifth Avenue. Continue on Fifth Avenue until you reach South Aiken Avenue. Turn right onto South Aiken Avenue.

To park at the Medical Building Garage: At the third stoplight on South Aiken Avenue, turn left onto Centre Avenue. At the first stoplight past the hospital, turn left into the Medical Center Garage.

TO RECEIVE THE DISCOUNTED PARKING RATE, PLEASE PARK IN THE MEDICAL BUILDING OR SOUTH AIKEN GARAGE.

 

For further directions and information on parking, please visit http://shadyside.upmc.com/Locations.htm or contact Kyessa L. Brian at 412-802-6905.
CONTINUING EDUCATION CREDITS

Psychologists Western Psychiatric Institute and Clinic is approved by the American Psychological Association to offer continuing education for psychologists.  Western Psychiatric Institute and Clinic maintains responsibility for this program and its contents. The program is being offered for 13.0 continuing education credits.

Certified Addiction Counselors (CAC):  Western Psychiatric Institute and Clinic/Office of Education and Regional Programming is certified by the Pennsylvania Certification Board (PCB) to provide Certified Addictions Counselor (CAC) continuing education credits for those participants attending the entire program; 13.0 PCB hours have been approved for participation in this conference.

Certified Psychiatric Rehabilitation Practitioners (CPRP): A total of 13.0 credit hours can be applied to training hours for the Certified Psychiatric Rehabilitation Practitioner (CPRP).

Counselors: Western Psychiatric Institute and Clinic is recognized by the National Board for Certified Counselors (NBCC) to offer continuing education for National Certified Counselors. Western Psychiatric Institute and Clinic adheres to the NBCC continuing education guidelines. The program is being offered for 13.0 continuing education credits.

Social Work: LSW/LCSW/LPC/LMFT
The indicated number of clock hours of continuing education is provided through co-sponsorship of the University of Pittsburgh School of Social Work, a PA-approved provider of social work continuing education.  These clock hours satisfy requirements for LSW/LCSW, LPC and LMFT renewal.  For information of social work continuing education, call (412) 624-3711.

 

Educators (Act 48): Western Psychiatric Institute and Clinic is recognized by the Pennsylvania Department of Education to offer continuing education credits under Act 48 guidelines. 

 

All Health Care Professionals: Other health care professionals are awarded 1.3 continuing education units (CEUs).

 

EMS: This course has been pre-approved for EMS credit.