Thank you for your interest in being trained to become a certified My Life My Choice Prevention Curriculum group facilitator. Completing this application is the first step in the certification process.  You will be notified of your application status within three business days of submission.  Applications and any questions should be directed to the Director of Prevention, Amy Corbett at acorbett@jri.org.   

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* 1. Personal Information

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* 2. Employer Information

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* 3. Are you interested in Social Work or LMHC CEU's?

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* 4. Please check all that apply to your experience and provide details below.

**If you identify as a survivor of commercial sexual exploitation or trafficking, you are invited to attend a survivor networking breakfast from 9-10am on day 2 of the training.

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* 5. Please describe your experience facilitating groups for youth:

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* 6. I identify my gender as:

My Life My Choice believes that it is best practice for people who identify as female to facilitate these groups. If you identify as male and are interested in facilitating a group, please contact Amy Corbett (acorbett@jri.org).

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* 7. Are you bilingual/multilingual?

Prior training on Commercial Sexual Exploitation is a pre-requisite to attend the My Life My Choice Prevention Curriculum Training.

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* 8. Have you participated in the full day My Life My Choice training on Understanding and Responding to Victims of Commercial Sexual Exploitation?

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* 9. If you answered "no" to the previous question, have you had prior training on the Commercial Sexual Exploitation of Children (CSEC) in the past year?

If you have not attended a training on CSEC, you will need to attend this training prior to registering for the My Life My Choice Prevention Curriculum Training. Please contact Amy Corbett-acorbett@jri.org for more information.
The My Life My Choice group/curriculum is designed to be facilitated at the site/agency where you are employed when you are trained.

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* 10. Please tell us about the site where you are employed and intend to facilitate the My Life My Choice Prevention Curriculum.

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* 11. Are you a faith-based organization?

Please note that My Life My Choice is a secular curriculum. If you have questions concerning this, please contact Amy Corbett at acorbett@jri.org
The My Life My Choice Prevention model requires that groups are co-facilitated: best practice is by a survivor of CSEC and an experienced clinician.

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* 12. Do you plan to facilitate a My Life My Choice Prevention Group at your site/agency?

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* 13. Do you plan to send two people from your agency to this training?

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* 14. A CSEC Policy for your site/agency, that includes mandated reporting (if applicable to your State), for handling disclosed or suspected exploitation, must be in place in order to facilitate a My Life My Chioce Prevention Group. Please attach here:

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* 15. If you do not have a CSEC policy in place, are you committed to developing a policy and submitting it to My Life My Choice within 3 months?

Please note, you are not eligible to facilitate a prevention group until a CSEC policy is in place.

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* 16. Do you have a plan in place for appropriate referrals to support a youth who discloses CSEC? (Please include this info in your CSEC policy).

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* 17. Do you have a relationship with local law enforcement in order to support a youth who discloses CSEC?

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* 18. If you are a 24 hour program, do you have staff on each shift who have been trained in responding to disclosures around the Commercial Sexual Exploitation of Children?

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* 19. Is your agency administrator aware and in support of the use of the curriculum in your program?

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* 20. Please enter your agency administrator's contact information

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* 21. Please attach your resume here:

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* 25. Would you like to receive the curriculum (and facilitate groups) in English or Spanish?

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* 26. How did you hear about the My Life My Choice Prevention Curriculum Training?

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* 27. Do you have any other questions?

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