March 10, 2022: My Life My Choice Advanced Clinical Training Application  Survey

Thank you for your interest in the My Life My Choice Advanced Clinical training. Completing this application is the first step in the approval process. You will be notified of your application status within three business days of submission. Any questions should be directed to Niah Tobarri, Prevention & Training Coordinator, at ntobarri@jri.org.

1.Personal Information(Required.)

Name

Job title

Work Email

2.Agency Information(Required.)

Agency name

Agency address

City/Town

State/Province

ZIP/Postal Code

4.How would you describe your role?(Required.)

Clinician

Social Worker

Administrator

Director

5.Please check all that apply to your experience and provide details below.(Required.)

Masters' 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

Experience facilitating groups with youth

6.The age and gender identity of my clients are:(Required.)

Prior training on Commercial Sexual Exploitation is a prerequisite to attend the Advanced Clinical Training.

7.Have you participated in a full day training on understanding and responding to victims of commercial sexual exploitation?(Required.)

Yes

No

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

8.If you answered "no" to the previous question, have you had any other type of prior training on the commercial sexual exploitation of children (CSEC) in the past two years?(Required.)

Yes (see below).

No

I am registered to attend an upcoming CSEC training (see below).

If yes or attending an upcoming training, please note the title, date, name of the host agency, and format of training (webinar, full day, half day, etc.).

9.Are you a faith-based organization?(Required.)

Yes

No

Other (please specify)

10.Does your program currently partner with or have access to a survivor-led CSEC agency?(Required.)

Yes

No

If yes, which agency?

11.How did you hear about the My Life My Choice Advanced Clinical Training?(Required.)

Other / Please specify your colleague's name and organization if applicable:

12.Are you interested in Social Work CEU's?(Required.)

Yes

No/does not apply to me.

If yes, please enter license number

13.Do you have any other questions?