Blackfalds & District Victim Services ___________________________________________________________________________________________________________ . > P.O. Box 1780, 4405 South Street, Blackfalds, AB T0M 0J0 email firstname.lastname@example.org 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: email@example.com 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 firstname.lastname@example.org Gloria.email@example.com 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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