REGISTRATION
FORM
CISM: Group
Crisis Intervention (PN66)
(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:
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□
NBCC
Counselor (NBCC #_________) |
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|
□
Educator
(ACT 48) |
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□
Nurse |
□
Psychologist |
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SW/LPC/LMFT |
□
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CPRP |
□
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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: Group Crisis
Intervention (PN66)
December 2-3, 2008
OVERVIEW:
This 4th edition of the program is
designed to present the core elements of a comprehensive, systematic and
multi-component crisis intervention curriculum
The course prepares participants to understand a wide range of crisis
intervention services including pre-and post-incident crisis education,
significant other support services, on-scene support services, crisis
intervention for individuals, demobilizations after large-scale traumatic
incidents, small group defusings, and the group
intervention known as Critical Incident Stress Debriefing (CISD). The Basic CISM course is a peer-to-peer
training and specifically prepares participants to provide several of these group crisis intervention, specifically
demobilizations, defusings and the CISD. The need for appropriate follow up services
and referrals when necessary is also described.
EDUCATIONAL OBJECTIVES:
At the conclusion of this
program, participants should be able to:
·
Define
stress, CIS, and PTSD;
·
List
the common causes of Critical Incident Stress;
·
List
the effects of Critical Incident Stress;
·
Identify
the most common critical incidents;
·
List
the 10 basic interventions of CISM;
·
Define
and describe in detail the CISM group processes of demobilization, defusing,
and debriefing.
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 and Comprehensive Crisis Management
Trainers ……………………. $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
WPIC/OERP
4601
Telephone: 412-802-6905
Fax: 412-802-6910
Email: briankl@upmc.edu
http://www.wpic.pitt.edu/oerp
From
the East
Take the Parkway East (Route 376) to Exit 7 (Edgewood/Swissvale). At the end of
the exit ramp, turn right onto
To park at the
TO RECEIVE THE DISCOUNTED PARKING
RATE, PLEASE PARK IN THE
For
further directions and information on parking, please visit http://shadyside.upmc.com/Locations.htm or contact Kyessa L. Brian at 412-802-6905.
Social Workers: For social workers, 14.0 credit hours
of continuing education are 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 1.4 continuing
education units (CEUs).