Pre-Training: August 16, 2024
Virtual Training
First Name: Last Name:
Gender: Ethnicity/Race:
1. What languages do you speak?
2. What languages will you offer CPP in?
3. Primary email address
Please provide an email address that works well with accepting Google Documents and allows membership into Google Groups.
4. What is your most advanced degree?
Master's
Doctoral level student
Doctoral or higher
5. Select your discipline:
Licensed Mental Health Counselor: LPCC
Marriage and Family Therapist: MFT
Social Worker: ASW, MSW, LCSW
Psychologist: Psy.D., Ph.D.
Psychiatrist: M.D.
Other Medical Doctor: M.D.
Nurse specializing in mental health
6. Are you licensed in the state of Florida?
Yes
No
7. What is your license number
(including registered intern number)
8. If you are not fully licensed please provide the name and email address of your qualified supervisor
9. Primary Role in CPP Training:
Licensed Staff Therapist
Unlicensed Staff Therapist, Registered Intern
Supervisor
Senior Leader
Supervisor & Senior Leader
Other
10. Agency Name:
11. Agency Address:
12. Agency Supervisor:
13. If you are in private practice, please list the agency or group to you have identified to receive reflective consultation with during training.
14. What is your agency's plan for reflective supervision during the 18-month Learning Collaborative?
Minimum twice a month provided by the agency
Minimum twice a month offered by a contracted provider for the agency
15. Who will provide reflective supervision for your agency?
16. What level of experience does this supervisor have with infant mental health, dyadic work, reflective supervision and working on a multidisciplinary team?
17. Does your agency have adequate referrals of children 0-5 who have experienced at least one traumatic event to support you with meeting the minimum case requirements? Minimum requirements for 18-month training: Clinicians treat at least 4 CPP clients. Supervisors who want to be rostered - at least 2 CPP clients. Children are aged 0-5 and experienced at least one traumatic event.
Yes No
If no, is there a plan for cultivating additional referrals as part of engaging in this training?
Yes No N/A
18. Will your agency allow you to see CPP clients on at least a weekly basis?
Yes No
19. Is there a limit to the number of session you can provide?
Yes No
20. Are there time limits related to how long you can work with a family (e.g. 6 months, 1 year)
Yes No
21. Are you planning on treating families in Early Childhood Court using CPP?
Yes No
22. What counties do you plan to offer CPP in?
23. How much experience have you had with CPP?
None
Read about the model
Read parts of the manual
Read the manual - completely
Attended an introductory workshop
24. This Learning Session will be conducted virtually. Does you agency support stable Wi-Fi connectivity for trainees?
Yes No
25. Do you foresee any difficulties being allowed to videotape sessions and share them with the CPP trainers?
Yes No
26. Describe your experience working with children under the age of 5.
27. Describe your experience working with children and adults who have experienced trauma.
28. Please describe any trainings you have taken on topics of Infant Mental Health.
29. Briefly explain your reason for wanting to become a rostered CPP clinician.