Assessing and Managing Suicide Risk Application (AMSR)

Assessing and Managing Suicide Risk Application (AMSR)
AMSR Training for Trainers ­ Call For Applicants
Through funding provided by the Garrett Lee Smith State and Tribal Suicide Prevention Grant, the Department of Health Care Services (DHCS) is actively looking for interested parties wanting to be an authorized Assessing and Managing Suicide Risk (AMSR) trainer. Here are some compelling reasons to become an authorized AMSR trainer: 1) To provide a valuable high quality service to your community. 2) To stay up­to­date on trends related to suicidal behavior and prevention strategies. 3) Potential supplemental income. 4) To HELP OTHERS IN NEED! 1. The AMSR New Leader Training (NLT)
AMSR workshop leaders are experienced clinicians and teachers who are certified by the
Suicide Prevention Resource Center (SPRC). The NLT offers candidates for authorization
a demonstration of workshop facilitation by SPRC’s most experienced Master Trainers,
and the opportunity to practice and get feedback on presenting key modules of the
workshop. New leaders leave the NLT ready to deliver their first workshop and achieve
authorization as an AMSR workshop leader.
The AMSR NLT is a 2­1/2 day experience. Day 1 of the training will allow participants to
experience AMSR. Day 2 and the morning of day 3 will be devoted to learning how to
deliver AMSR. As per the SPRC requirements, all trainees must meet the following
minimum requirements:
Please check off each item to indicate you qualify:
c A Masters level degree or higher in a mental health profession.
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c Currently licensed to practice in California.
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c Five or more years as a practicing clinician in an outpatient clinical setting.
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c Familiarity with the subject matter (maintaining an effective attitude and approach to suicidal clients, collecting accurate information, d
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formulating risk, developing a treatment and service plan, and managing care) as evidenced by: lecturing, attending workshops/conferences, publishing, supervising, training graduate students, and/or research in clinical suicidology. c Letter of recommendation. The letter needs to have a date, signature, and contact information for the person writing the letter.
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c A copy or image of your current active clinical license.
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*2. Do you meet the criteria listed above?
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AMSR Training for Trainers ­ Call For Applicants Page 2
3. Thank you for your time in this application process. If you are one of the selected
participants, either SPRC or EDC will contact you.
The following dates, times, and locations have been scheduled for the NLT. Please keep
your calendar open for these dates as you must attend all three days to complete the
AMSR training.
Day 1
June 10, 2015
8:00 a.m. ­ 5:30 p.m.
Health Services Administration Building (HSAB)
Auditorium/Lobby
313 N. Figueroa Street
Los Angeles, CA 90012
*Parking will be approximately $8.00 and not covered by the grant.
Day 2
June 11, 2015
8:00 a.m. ­ 5:30 p.m.
Burton W. Chace Park
Community Room
13650 Mindanao Way
Marina Del Rey, CA 90292
Day 3 (Partial Day)
June 12, 2015
8:00 a.m. ­ 12:30 p.m.
Burton W. Chace Park
Community Room
13650 Mindanao Way
Marina Del Rey, CA 90292
Please submit a copy of your License and the letter of recommendation electronically. At
the end of this application you will create a unique identifier to be placed on all
correspondence. You can then send all correspondence to [email protected].
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The following is important information about the training. Please check each line item to
indicate that you are aware of the information and requirement.
Important Information and Requirements:
c The cost of the training is covered by DHCS (only for training and manuals).
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c Any lodging, food and travel expenses incurred by you will not be reimbursed.
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c Soon after completion of the AMSR NLT, trainers will be expected to conduct a Trial Workshop within their own organization or region of d
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the state ­ for no more than 15­20 participants. The AMSR Participant Manuals for this Trial Workshop will be available for purchase directly from Education Development Center (EDC). You may charge your Trial Workshop participants for these materials if you wish. Additional information about how to purchase these manuals will be provided at the NLT. These training materials are not provided by DHCS. c Upon satisfactory completion of the Trial Workshop, the trainer will be expected to facilitate a minimum of two AMSR workshops within d
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the following 12 months. EDC/SPRC will work with authorized trainers to schedule workshops. The cost of materials for these required AMSR trainings will be covered by the organizations sponsoring the workshops. DHCS does not fund or sponsor these trainings. c EDC's AMSR Staff and the Master Trainer will decide which AMSR NLT participants will become certified AMSR Trainers.
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c Participants in the AMSR NLT will receive 6.5 continuing education credits upon completion of the training. AMSR is authorized by d
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NASW and NBCC to award continuing education credits. Continuing Medical Education (CME) credits are also available. An application to award LMFT credits has been submitted and may possibly be available at the time of the training. 4. What To Expect After Completing the NLT
• For AMSR workshops you conduct, a per­participant fee will be charged to the
sponsoring organization.
• Sponsoring organizations — typically behavioral health organizations — enter into
contracts with the AMSR program to have workshops provided. Sponsoring organizations
pay the AMSR program a per­participant fee. You may collect a trainer fee and receive
reimbursement for travel if you wish. The AMSR program coordinates these details on the
trainer’s behalf.
• All AMSR trainers are required to sign a faculty agreement promising to use AMSR
materials only to conduct workshops contracted with the AMSR program.
Please indicate that you have read and understand Section 4 "What To Expect After
Completing the NLT."
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5. Please enter in the box below any questions or concerns you may have about the
expectations you have just read. AMSR program staff will contact you to clarify the
expectations. This will not be used to evaluate your application and will not be a
determining factor for your participation. (150 words or less)
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6 *6. There are a limited number of seats available for this training. Not everyone that
applies will be selected. Please remember to answer all questions on this application as
thoroughly as possible. Participant selection will be based on your answers.
(If you have not already filled out or composed your answers to the application questions
then you may want to select "No" to the following question and use the PDF that was
attached to the notice you received to compose your answers in advance.)
Once you start the application there is no time limit to complete, but there is not a way to
stop and come back at a later date. If you have already composed your answers then the
process should take approximately 20 minutes, depending on if you are transcribing your
answers or if you "cut and paste" from a word processing program. If you have not
composed your answers in advance, the application can take up to an hour to complete.
Do you wish to complete and submit this application?
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Personal Information (1 of 5 sections)
7. Last Name
8. First Name
9. Middle Name (If none, please leave blank)
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Assessing and Managing Suicide Risk Application (AMSR)
Personal Information (2 of 5 sections)
10. Please provide your mailing address.
Street/PO Box Number
City
State
Zip
11. Email Address? (If none, please enter N/A)
12. Please provide the best phone number to reach you. (XXX­XXX­XXXX) (Please enter
N/A if there is no phone number.)
Work
Cell
Home
Alternate
Fax
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Personal Information (3 of 5 sections)
13. Please provide your type of Professional License.
14. Please provide the State where your license is issued, including the year obtained and
the year of expiration.
State of Licensure
Year Obtained
Expiration Year
15. Please select your highest degree.
6 16. Please list the Institution and Date Awarded of your highest degree.
Institution Name
Date Awarded
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Personal Information (4 of 5 sections)
17. Please provide the name of your current employer. (If self employed or you have your
own practice please answer "SELF".)
18. Please provide the following information regarding your current employer.
Street Mailing Address
City
State
Zip Code
Work Number (XXX­XXX­
XXXX)
Email
Position Title
Length of employment in years
(If Same As Your Home Address, Please Write "Home")
19. Please describe the practice setting.
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Personal Information (5 of 5 sections)
20. Please tell us your gender. (This Question Is Optional)
6 21. Do you consider yourself to be: (This Question Is Optional)
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Interest Questions
22. Please tell us why you are interested in becoming a trainer for Assessing and
Managing Suicide Risk? (150 words or less)
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6 23. Describe your experience assessing and forming a judgment about the suicide risk of
clients/patients. (150 words or less)
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24. Please describe one lesson you've learned as a result of your experience assessing
and managing clients at risk for suicide. (150 words or less)
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6 25. Describe your experience planning treatment for and managing suicidal
clients/patients. (150 words or less)
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26. Describe your experience working as a clinician with racial and ethnic minority
persons. (150 words or less)
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Clinical Experience
Please use the following section to describe your clinical experience as it relates to: 27. Outpatient mental health treatment
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6 28. Years of Experience for Outpatient Mental Health Treatment?
29. During your Outpatient Mental Health Treatment, was it full time, part time or not
applicable (N/A)?
j Full Time
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j Part Time
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j N/A
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30. Outpatient substance abuse treatment
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6 31. Years of Experience for Outpatient Substance Abuse Treatment?
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32. During your Outpatient Substance Abuse Treatment was it full time, part time or not
applicable (N/A)?
j Full Time
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n
j Part Time
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j N/A
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33. Inpatient psychiatric treatment
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6 34. Years of Experience for Inpatient Psychiatric Treatment?
35. During your Inpatient Psychiatric Treatment, was it full time, part time or not applicable
(N/A)?
j Full Time
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j Part Time
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j N/A
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36. Emergency department
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6 37. Years of Experience for the Emergency Department?
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38. During your work in the Emergency Department was it full time, part time or not
applicable (N/A)?
j Full Time
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j Part Time
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j N/A
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39. Crisis services (e.g., mobile crisis unit)
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6 40. Years of Experience in Crisis Services?
41. During your work in Crisis Services, was it full time, part time or not applicable (N/A)?
j Full Time
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j Part Time
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j N/A
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42. Residential treatment
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6 43. Years of Experience in Residential Treatment?
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44. During your work in Residential Treatment, was it full time, part time or not applicable
(N/A)?
j Full Time
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j Part Time
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j N/A
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45. Day Treatment / Partial Hospitalization
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6 46. Years of Experience in Day Treatment/Partial Hospitalization?
47. During your work in Day Treatment/Partial Hospitalization, was it full time, part time or
not applicable (N/A)?
j Full Time
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j Part Time
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j N/A
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48. Case management
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6 49. Years of Experience in Case Management?
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50. During your work in Case Management, was it full time, part time or not applicable
(N/A)?
j Full Time
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n
j Part Time
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j N/A
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51. Supervision of clinicians
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6 52. Years of Experience with the Supervision of Clinicians?
53. During your work Supervising Clinicians, was it full time, part time or not applicable
(N/A)?
j Full Time
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j Part Time
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j N/A
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54. Clinical director
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6 55. How many years of experience as a clinical director?
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56. Was your work as a Clinical Director full time, part time or not applicable (N/A)?
j Full Time
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n
j Part Time
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j N/A
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57. Other: Specify
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6 58. How many years of "other" experience do you have?
59. Was this "other" work full time, part time or not applicable (N/A)?
j Full Time
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n
j Part Time
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j N/A
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Please detail your training experience: 60. Presentations to staff
Topic(s):
Number of times delivered:
61. Presentations in the community
Topic(s):
Number of times delivered:
62. Presentations at statewide conferences
Topic(s):
Number of times delivered:
63. Presentations at national conferences
Topic(s):
Number of times delivered:
64. Conducted training (Grad Students)
Topic(s):
Number of times delivered:
65. Conducted training (Clinicians)
Topic(s):
Number of times delivered:
66. Conducted training: National Conferences or Meetings
Topic(s):
Number of times delivered:
67. Taught graduate level courses
Topic(s):
Number of times delivered:
68. Other (Specify)
Topic(s):
Number of times delivered:
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69. Describe your experience training clinicians who serve racial and ethnic minority
persons. (150 words or less)
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6 70. Have you ever experienced a personal or clinical loss to suicide? If so, what did you
take away from the experience? (150 words or less)
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In Conclusion
Thank you for taking the time to complete this application. Someone from the California Department of Health Care Services and/or the Education Development Center will be in contact. To complete your application, follow the instructions that came with the link to this application. The next section is to create a unique identifier for your application. Please follow the directions and then place the identifier on all correspondence. You may email your license copy, letter of recommendation, and any other information you wish to EDC at [email protected]. Be sure to place your unique identifier on all attachments and emails. *71. Please enter the first 3 letters of your last name.
*72. Please pick a random 2 digit number (10­99)
*73. Please confirm your 5 digit zip code
Your unique identifier is the first three letters of your last name plus your random two digit number and your zip code. Please be sure to use this in all correspondence. Please be sure to click "next" to populate your unique identifier. Page 21
Assessing and Managing Suicide Risk Application (AMSR)
This is your unique identifier.
[Q71][Q72][Q73] Please be sure to use this on all correspondence. If you have questions you may contact [email protected] ­or­ Lisia Morales at EDC. [email protected] 74. Thank you for your interest in AMSR­NL training. Please select "finished" on the drop
down menu to complete your application.
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Thank You For Your Time
75. To close this survey, please click "Yes". To navigate back, select "No".
j Yes, Please Close This Survey
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j No, Please Do Not Close This Survey
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