Each Applicant Is to Individually Complete the TI-CPP Application and Include the Names

ApplicationForm

Each applicant is to individually complete the TI-CPP application and include the names of their team members

ApplicantInformation:

FirstName: / LastName:
Degree: / LicenseType: / License#:
InstitutionwhereDegreeObtained: / YearDegreeObtained:

HaveyoucompletedtheUniversityofWisconsinInfantandEarlyChildhoodMentalHealthCertificateProgram: Ifyes,datecompleted:

Haveyoucompletedinfantandearlychildhoodmentalhealthprograminanotherstate?Ifyes, whatwasthenameofyourprogramandwhendidyoucompleteit?

JobTitle:

Address: / PrimaryPhone:
OtherPhone(ifapplicable):
City: / State: / Zip: / FaxNumber:

Applicant’s E-mail:

Name: PrimaryRole:(Selectone.)

ClinicalSupervisorClinician

SecondaryRole,ifapplicable:(Selectone.)

SeniorLeaderClinicalSupervisorClinicianOther,specifyrole:

OrganizationInformation:

AgencyName: / Website:
Countiesservedbyorganization:

ProgramManager(Contactpersonregardingthisproposal):

ProgramManager’sAddress: / ProgramManager’s Phone:
City: / State: / Zip:

ProgramManager’sE-mail:

ClinicalSupervisor:SupervisorPhone:SupervisorE-mail(ifdifferentfromprogrammanager):

ExecutiveDirector:ExecutiveDirectorPhone:ExecutiveDirectorE-mail:

ServicesProvidedbyOrganization: / Outpatient /
Rehabilitative / DayTreatment
Co-LocatedServices–Site:
Other-List

WhichservicesareprovidedbyApplicant?

WisconsinTI-CPPCohort2TrainingApplicationPacket

1of5

Diagnosesand/orpresentingproblemsservedbyOrganization: / Age-RangeServedbyOrganization:
Diagnosesand/orpresentingproblemsservedbyApplicant: / Age-RangeServedbyApplicant:

Pleaseidentifyyourteam.Noteeachteammemberwhointendstoparticipateinthetrainingsmustcompletehis/herownapplication.TeammemberswhoserveonlyasSeniorLeadersdonotneedtocompleteanapplication.

TeamMember#1

Name:Title:

Credentials:(e.g.,LCSW,Ph.D.,LPC,etc.):

Discipline:(e.g.,SocialWork,Psychology,Psychiatry,MentalHealthCounselor,MarriageandFamilyCounselor,etc.):

TelephoneNumber:EmailAddress:MailingAddress:

PrimaryRole:(Selectone.)

ClinicalSupervisorClinicianSeniorLeaderOther,specifyrole:

SecondaryRole,ifapplicable:(Selectone.)

SeniorLeaderClinicalSupervisorClinicianOther,specifyrole:

TeamMember#2

Name:Title:

Credentials:(e.g.,LCSW,Ph.D.,LPC,etc.):

Discipline:(e.g.,SocialWork,Psychology,Psychiatry,MentalHealthCounselor,MarriageandFamilyCounselor,etc.):

TelephoneNumber:EmailAddress:MailingAddress:

PrimaryRole:(Selectone.)

ClinicalSupervisorClinicianSeniorLeaderOther,specifyrole:

SecondaryRole,ifapplicable:(Selectone.)

SeniorLeaderClinicalSupervisorClinicianOther,specifyrole:

TeamMember#3

Name:Title:

Credentials:(e.g.,LCSW,Ph.D.,LPC,etc.):

Discipline:(e.g.,SocialWork,Psychology,Psychiatry,MentalHealthCounselor,MarriageandFamilyCounselor,etc.):

TelephoneNumber:EmailAddress:MailingAddress:

PrimaryRole:(Selectone.)

ClinicalSupervisorClinicianSeniorLeaderOther,specifyrole:

SecondaryRole,ifapplicable:(Selectone.)

SeniorLeaderClinicalSupervisorClinicianOther,specifyrole:

QUESTIONSFORCLINICIANSANDCLINICALSUPERVISORS

1.CPPhasbeendemonstratedtobeefficaciouswithchildrenundertheageofsixexposedtotraumaandtheirprimarycaregivers.Itisaflexiblemodalitythatcanbedeliveredinthe clinic orin the family’shome.

a.Whatisthetargetpopulation(s)withwhichyouplantoimplementCPPduringthistraining?

b.Pleasedescribethesetting(s)inwhichthepracticewillbeimplemented,agerangeofthechildrenwhowillreceiveCPP,andtypesoftraumathefamilieshaveexperienced.

2.Describeyourknowledgeofearlychildhooddevelopment(bothnormalandclinicalpopulations).Whatexperiencedoyouhaveworkingwithinfantsandveryyoungchildrenandtheircaregivers?(PleaseincludelistinganddocumentationofInfant/EarlyChildhoodMentalHealthCertificateprogramcompletionorequivalenttraining/supervisedexperienceandorEndorsement.)

3.Whatexperiencedoyouhaveworkingwithadults(parents/caregivers)andfamilieswithmentalhealthand/ortraumarelatedsymptomsorexperiences?

4.Atpresent,whattypeoftherapydoesyoursite typicallyprovideforfamiliesseekingtreatmentfortheiryoungchildrenand/ortofamiliesseekingassistancewithtrauma-relatedsymptomsorexperiences?

5.Pleasedescribeyourtrainingandexperienceinusingevidence-basedpracticesinmentalhealthtreatment.

6.HowdoyouplantoidentifypotentialCPPclientsandwhenwilltheprocessofidentifyingandscreeningclientsforCPPbegin?

7.Eachsiteshouldconductanassessment(includingfortraumaexposureandexperiences)toallchildrenandcaregiversreceivingCPPatthestartandendoftreatment.Doyouforeseeanydifficultiesobtainingorscoringthemeasures?Ifso,howcanyouaddresstheseissues?

8.ClinicianswillbeaskedtocompleteseveralfidelityformstoassesseffectiveimplementationofCPP.Doyouforeseeanydifficultieswiththecompletionandreviewoftheseforms?

9.Brieflydescribetherangeofdiversityinthechildren(0-6)andfamiliesyouserveandhowyourworkreflectsanawarenessofculturaldifferences.Eachindividualorfamilyrepresentsauniqueconstellationofexperiencesandculture.Diversitymayencompassage,gender,sexualorientation,ethnicity,raceclass,countryoforigin,religiousorspiritualbeliefs,physicalcharacteristics,motororcognitiveabilities,familyconstellation,orotherdifferencesforpurposesofthisapplication.(Limit200words)

10.Pleasedescribeanyotherexperiences,training,orfactorsthatprepareyouforthisTraumaInformed-ChildParentPsychotherapy.

11.WillyouneedsupportobtainingReflectiveSupervision/ConsultationorwillyoursupervisorparticipateinthisTI-CPPtraining?

12.Pleasedescribeyourinterestinandneedforfinancialassistancethroughthescholarshipsavailable.

QUESTIONFORCLINICALSUPERVISORS

13.Describethemodelthatisusedforclinicalsupervisionatyoursite.

14.PleasedescribeyourtrainingtoprovideReflectiveSupervision.

QUESTIONSFORSENIORLEADERS

15.Hasyourteamexperiencedanybarrierstosuccessfullytreatingyoungchildrenwithtrauma-relatedsymptomsand/orparent-childrelationshipissues?Ifso,please list.

16.Howwillyouensureagencybuy-intosupportthetrainingandimplementationofCPPduringthetraining?

17.WhatarethekeychallengesyourorganizationfacesimplementingandsustainingtheuseofCPPatyoursite?

18.Howcanyouaddressanychallengesrelatedto thelong-termuseofCPPatyoursite?

19.HowwillyouworktoensurethatChild-ParentPsychotherapytakesholdandwillbeimplementedwithsufficientfidelityafterthetrainingends?

OrganizationExecutiveDirector(agencyhead)certifiesthat:

Y / Initials / NO / Date / Statement
1.TheorganizationisenrolledtoprovideMentalHealthServicesthroughMedicaid?
2.AssuranceofEmployeeFullParticipation.Theorganizationwillallowtimefortrainee(s)toparticipateinthree onsitetrainingandsemi-monthlytelephonedconsultationbeginninginNovember,2014throughMay,2016(18months).
4.AssuranceofMeetingTrainingRequirements.Theorganization willprovide applicant’s time toattendtheone three-day trainingandtwotwo-dayinpersontrainings.
5.AssuranceofEmployeeParticipationinConsultation.Theorganizationwillprovidetrainee(s)timetoparticipateinsemi-monthly(twice amonth)telephoneconsultation/meetings.Consultationisprovidedfor onehourtwiceamonth,beginningimmediately,andcontinuesfor18months.Thetraineemustsee4familiesusingTI-CPPduringthecourseoftraininginordertobecertifiedinthetrainingandusealloftheprescribedscreening,assessment,andfidelitymeasuresrequiredbythetrainer(s).Thetraineemustpresentatleasttwocasesoftheirclinicalworkusingthe TI-CPPtrainingduringthecourseofthetrainingcohort.
6.AssuranceofCompletionofCertification.TheapplicantortheorganizationwillreimbursetheamountofthescholarshipprovidediftheapplicantdoesnotcompletetherequiredcertificationprocessforTI-CPP.

ApplicantAgreementtoCompleteandSignature:

IhavereadtherequirementsfortraininglistedintheTraumaInformedPrintApplicant’sName)CPPTrainingAnnouncement.IfselectedforTI-CPPTraining,Iagreetocompletethelistedrequirements.
Signature: / Date:

PROPOSALAUTHORIZATION

Name of Applicant’sExecutiveDirector:
Signature: / Date:
Name of Applicant’sClinicalSupervisor
Signature: / Date:

Pleasesendyourcompletedapplicationto:Krista Duffy, Program Coordinator, by Email Attachment: ; Fax: 608-263-0265; Address: WISPIC/Department of Psychiatry, 6001 Research Park Blvd, Madison, WI 53719

TI-CPP Scholarship Application: To be considered for a TI-CPP scholarship to assist with your registration fees, complete the following scholarship application: