WTC Responder Application Form

The Workplace Trauma Center is always looking for qualified crisis responders throughout the world. Please carefully review our minimum requirements before filling out the application.

If you have any questions about whether your qualifications meet our requirements please call us at 410 363-4432.

Minimum Requirements:

- A Masters Degree or higher in a mental health field
- A License to practice at the independent level
- Professional liability insurance
- Training in Critical Incident Stress Management preferred, but comparable training will be considered
- Experience in providing on-site corporate crisis support

Once you have submitted this form please send the following documentation to us by fax at 410 970-4529, or by email to rjo@workplacetraumacenter.com:

1. Graduate diploma
2. Professional license
3. Professional Liability Insurance verification
4. Critical Incident or crisis management training certificates

Please start the Application process by filing out the online form below and submitting it to us.

* Required

First Name *

Middle Initial

Last Name *

Street Address *

Street Address

City *

State *

Zip/Postal Code *

Country

Email Address: *

Work Phone #

Home Phone #

Cell Phone #

Fax #

Prefered Number(s) for us to call you: *

Cell
Work
Home
Other:

State, License type, License number i.e.: NJ, LCSW-C, 1234

Training Received *

Availability Weekdays *

Rarely
Occassionally
Frequently
Other:

Availability Evenings *

Rarely
Occassionaly
Frequently
Other:

Availability on Weekends *

Rarely
Occassionaly
Frequently
Other:

Availability for immediate response *

Rarely
Occassionally
Frequently
Other:

Are you willing to travel overnight? *

Yes
No

Are you willing to travel internationally *

Yes
No

Do you have a valid passport? *

Yes
No

Please list metropolitan areas within 2 hours driving distance of where you live/work: *

Please list types of critical incidents you have responded to in the past 2 years: *

List any critical incident or crisis teams you are on: *

We offer training programs to our corporate clients. If you are interested in offering training programs,please list the programs you currently are able to offer.

Have you ever been convicted of a crime other than a misdemeanor traffic offense? *

Yes
No

Have you ever had a professional association, ethics or licensure board find you guilty of an ethics violation? *

Yes
No

Have you ever had privileges at any hospital, facility, or health plan, voluntarily or involuntarily surrendered, denied, suspended, revoked, restricted, limited or put on probation? *

Yes
No

Have you ever been placed on probation or asked to resign from a CISM team, disaster mental health team, or other crisis intervention program? *

Yes
No

Have any of your licenses, board certifications or professional association memberships been suspended, revoked or restricted in any way? *

Yes
No

Has your malpractice insurance ever been cancelled, suspended, restricted, limited, special rated or not renewed? *

Yes
No

Are you currently engaged in the illegal use of drugs? *

Yes
No

Is there any reason that you are not able to perform the essential functions of the position for which you have applied? *

Yes
No

Within the last (5) years have you been reprimanded or disciplined in any manner by any state licensing authority or professional board or peer committee for conduct related to the use of alcohol or the use of drugs? *

Yes
No

If you answered "yes" to any of the above or if you have any questions or concerns, please enter them below: Please use this item to make any comments or ask any questions.

I certify that all statements are correct and accurate! *

Yes
No

You are finished!

IMPORTANT: Before pressing the submit button please use your browser print command to print a copy of this form for your records. You cannot return to the form once it is submitted. Thank you for applying. If you have not heard from us within 2 weeks please call us at 410 363-4432.