REGISTRATION
FORM
CISM: Individual
Crisis Intervention and Peer Support & Group Crisis Intervention (PN57)
(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: Individual Crisis
Intervention and Peer Support & Group Crisis Intervention (PN57)
OVERVIEW:
This program is designed to teach
participants the fundamentals of, and a specific protocol for, individual
intervention and increase Emergency Mental Health skills and to present the
core elements of a comprehensive, systematic and multi-component crisis
intervention curriculum. The three day 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 group large
scale traumatic incidents, small group defusings and
the group intervention known as Critical Incident Stress Debriefing (CISD). The
“Group Crisis Intervention” course specifically prepares participants to
provide several of these interventions–specifically demobilizations, defusings and the CISD. The need for appropriate follow up
services and referrals when necessary is also described. Considerable evidence
gathered to date strongly supports the multi-component crisis intervention
strategy, which is discussed in this course.
EDUCATIONAL OBJECTIVES:
At the
conclusion of the program, participants should be able to:
· Define stress, CIS, and
PTSD
· List the 10 basic
interventions of CISM
· Define and describe in
detail the CISM group processes of demobilization, defusings
and debriefings
· List at least four
fundamental principles of crisis intervention
· Describe common
psychiatric symptoms after trauma
· Demonstrate individual crisis
communication techniques
· List risk factors for
suicide
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
Completion
of “Individual Crisis Intervention and Peer Support” & “Group Crisis
Intervention” and receipt of a certificate indicating full attendance (27
Contact Hours) qualifies as two
TUITION:
General
…….................................................$350.00
First Responders and Comprehensive Crisis Management
Trainers ………………………………………. $325.00
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, 27.0 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 2.7 continuing
education units (CEUs).