May 2019 Preventing Sexual Exploitation Among Adolescent Girls: The My Life My Choice Curriculum Training Application Survey

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

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

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* 2. Employer Information

Agency

Job Title

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

Yes

If yes, please enter license number

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

Master's Level Clinician

Survivor of commercial sexual exploitation**

At least 5 years of clinically related experience, specifically working with victims of trauma

Experience working with survivors of commercial sexual exploitation or human trafficking

Experience working with at risk youth

Please elaborate years of experience and provide additional details that you feel makes you an appropriate candidate to participate in this facilitator training:

**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?

Yes

If yes, what languages do you speak?

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?

Yes

If yes, please provide the date you attended the training.

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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?

Yes

Not Applicable, as I have had training by My Life My Choice in the past year (see above).

I am registered to attend a My Life My Choice (please enter date below).

If yes, please note the title of the training, the date you were trained and the agency that provided the training, including format of training (webinar, full day, half day, etc.).

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.

Community Based Ageny

Court/Probation

School

Juvenile Justice Facility

Group Home/Residential Program

Runaway/Homeless Youth Shelter

I am not connected to a site/agency

Other (please specify)

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* 11. Are you a faith-based organization?

Yes

Other (please specify)

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?

Yes

No, but I am supervising staff who will be facilitating groups at our site.

If you do not plan to facilitate groups, please describe your interest in this training

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

Yes

If no, please explain your plan for facilitating groups

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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:

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

No file chosen

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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?

Yes

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).

Yes

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

Yes

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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?

Yes

Not Applicable, as I am not at a 24 hour program.

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

Yes

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

Name

Email Address

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* 21. Please attach your resume here:

DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only.

Choose File

No file chosen

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* 22. I understand that by participating in this facilitator training, I will be required to sign and complete the My Life My Choice Licensing Agreement. (Once approved, you will receive a copy of this agreement to be signed).

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* 23. I understand that my agency will be required to submit a CSEC agency policy within 3 months of facilitator training and or/prior to initiating groups, if one is not already in place.

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* 24. I understand that to become certified as a My Life My Choice Prevention Curriculum facilitator, I must have prior training on the Commercial Sexual Exploitation of Children, either through My Life My Choice or another agency that qualifies.

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

English

Spanish

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

Through a colleague

My Life My Choice's website

At another My Life My Choice training

Training email

Other (please specify)

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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?

Question Title

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

Question Title

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

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* 6. I identify my gender as:

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* 7. Are you bilingual/multilingual?

Question Title

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

Question Title

* 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?

Question Title

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

Question Title

* 11. Are you a faith-based organization?

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

Question Title

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

Question Title

* 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:

Question Title

* 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?

Question Title

* 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).

Question Title

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

Question Title

* 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?

Question Title

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

Question Title

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

Question Title

* 21. Please attach your resume here:

Question Title

* 22. I understand that by participating in this facilitator training, I will be required to sign and complete the My Life My Choice Licensing Agreement. (Once approved, you will receive a copy of this agreement to be signed).

Question Title

* 23. I understand that my agency will be required to submit a CSEC agency policy within 3 months of facilitator training and or/prior to initiating groups, if one is not already in place.

Question Title

* 24. I understand that to become certified as a My Life My Choice Prevention Curriculum facilitator, I must have prior training on the Commercial Sexual Exploitation of Children, either through My Life My Choice or another agency that qualifies.

Question Title

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

Question Title

* 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?