Blackfalds & District Victim Services 403-348-9839 - DOC by Na9a2u

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									Blackfalds & District Victim Services
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P.O. Box 1780, 4405 South Street, Blackfalds, AB T0M 0J0                       email admin@victimsupport.ca
                             www.victimsupport.ca


Individual and Group Crisis Intervention Course Registration
Date:                  Friday, Saturday, Sunday May 25, 26, and 27, 2012
Location:              4401 South Street, Blackfalds Protective Services - Firehall
Time:                  Friday 6:00 pm - 10:00 pm
                       Sat & Sun 8:30 am - 5:00 pm

3 Easy Ways to Register: Email: gloria.derksen@rcmp-grc.gc.ca
                       Mail to: P.O. Box 1780, Blackfalds, T0M 0J0
                           Fax to: 403-885-4720 Attention: Gloria

Personal Information PLEASE PRINT OR TYPE
LAST NAME___________________________________________ FIRST NAME__________________________________________
Credentials (Maximum3)______________________________________________________________________________________
Address: ___________________________________ City/Prov _________________________________ PC: ________________
WORK PHONE NO. (______)_________________HOME PHONE NO. (_____)_________________ Cell (____) _____________
EMAIL (Block print clearly):_______________________________________________________________________
Company or Organization_________________________________________________________________________
PRIMARY OCCUPATION (Circle only one ): Psychologist | Social Worker | Substance Abuse Counselor | Counselor | Fire | EMS | Victim
Services | Law Enforcement | Nurse | Education | Human Resources | Healthcare | Military | Faith-Based Providers | Business &
Industry | EAP | Transportation | Student | Other: _________________________________________
Have you attended any prior CISM Courses? __ YES __ NO
How did you hear about the course? (Circle only one and list specifics):
- Friend or co-worker - Web Link _________________________ - Newspaper - Other _________________________________
Are you a member of a CISM Team? __ YES __ NO If Yes, provide Team Name: ____________________________________

CHECK ENCLOSED, $375.00 (includes materials, lunch, snacks) payable to Red Deer Rural Victim Services Society, $30.00 fee
on all returned checks. Class is Limited to first 30 PAID applications.


Gloria Derksen; CHRP - Executive Director
Blackfalds & District Victim Services Society
403-348-9839
admin@victimsupport.ca
Gloria.derksen@rcmp-grc.gc.ca


CISM – Critical Incident Stress Management Training

Combined Individual Support / Group Crisis Intervention (3 day program – Successfully complete this program and receive a
International Critical Incident Stress Foundation certificate for each class (Individual and Group Crisis Intervention) and 2.7 continuing
education units (CEU’s) issued by the University of Maryland, Baltimore County).

The Combined Individual Support/Group Crisis Intervention Course follows a progressive, adult-education based model that starts with
basic concepts associated with all types of crisis intervention. The focus then shifts to developing communications skills necessary for
individual peer support interventions with co-workers in crisis. The SAFER model for peer support interventions is taught prior to taking
the individual communications skills and using them as the foundation for developing the skills necessary to work with groups
experiencing reactions to trauma. The program moves through developing an understanding of, and practicing, the “toolbox” of group
interventions. Particular focus is placed on the most used group interventions, defusings, crisis management briefings and debriefings. The
course then concludes with a focus on developing the strategic planning skills necessary to determine the most appropriate intervention
that in indicated based on a number of factors including the target recipients, the timing and the situation.

      Trainer Steve Dongworth, Chief Superintendent, City of Calgary Public Safety Communications, whose employment history includes
      Deputy Chief with the Calgary Fire Department and over 35 years of service with professional fire services. Experienced CISM Team
      Coordinator, Peer Member, Trainer and Conference Speaker.

								
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