October 12th, 2022 - November 16th, 2022: Advanced Residential Institute Training Application Survey

Thank you for your interest in the My Life My Choice Advanced Residential Institute training. This is a 6 week online course that will meet once per week on Wednesday afternoons from 2:30-3:45pm EST. 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 Nikki Valila, Director of Training & Partnerships at nvalila@jri.org.

1.Personal Information(Required.)

Name

Job title

Work Email

Phone Number

2.Agency Information(Required.)

Agency name

Agency address

Is this a residential facility? Y/N

City/Town

State/Province

ZIP/Postal Code

3.Please tell us more about your program, including number of beds, average length of stay, and any specialization.(Required.)

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

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

Please provide any additional details that you feel makes you an appropriate candidate to participate in this training:

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

6.Have you participated in a a full day CSEC 101 training?(Required.)

Yes

No

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

7.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.).

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

Yes

No

Other (please specify)

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

Yes

No

If yes, which agency?

10.How did you hear about the My Life My Choice Advanced Residential Institute Training?(Required.)

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

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

Yes

No/does not apply to me.

If yes, please enter license number

12.The live sessions will be recorded for the use of participants and ongoing quality improvement for instructors. Do you consent to being recorded for these reasons?(Required.)

Yes

No

13.Do you have any other questions?