Mental Health Professional Development Request Form
District
School
*
Contact Person
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Choose the Training you are interested in
PREPaRE School Crisis Prevention and Intervention Training, Third Edition
Bullying 101 - 3 Hours
PA K-12 Threat Assessment Training - 6 Hours
Risk Assessment Training for School Psychologists, Counselors, and Social Workers - 4 Hours
Trauma 101 for Educators - 3 Hours
Trauma 101 for Clinicians - 3 Hours
Advanced Topics in Trauma Informed Care - 3 Hours
Vicarious Trauma and Self-Care Strategies for School Professionals Training - 3 Hours
Other
Which PREPaRE course are you interested in?
(PREPaRE 1, one full day) Admin Safety Staff
(PREPaRE 2, two full days) Mental Health Professionals
Training Details:
Date
/
Month
/
Day
Year
Date
Number of Participants
Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Training Time Requested
Full Day: 8:00am, Training 8:30-3:30 (6 hours)
Half Day AM: 8:00am, Training 8:30-11:30 (3 hrs AM)
Half Day PM: 12:00pm, Training 12:30-3:30 (3 hrs PM)
Intended Audience
(i.e., special ed teachers, general ed teachers, mental health staff, administrators)
Are there specific content areas of school/district needs you would like address?
Please indicate if your school/district is requesting the MCIU to provide Act 48.
My School/District is requesting the IU to provide Act 48. A link will be sent for participants to register. They must register one week in advance of the workshop.
My School/District does not request the IU to provide Act 48.
Please Note:
Presenters will arrive 30 minutes prior to start of training
Presenters will need access to audio/visual setup and internet
Training should be held in a climate-controlled room with adult-sized chairs for presenter and participants.
If you have any questions please contact Dr. Aviele Koffler - akoffler@mciu.org
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