WI-AIMH Reflective Supervision Learning Collaborative (RSLC) Application
Thank you for your interest in the WI-AIMH Reflective Supervision Learning Collaborative. Our goal in offering this learning opportunity is to increase statewide availability and accessibility of reflective supervision to support local agencies in pursuing IMH-Endorsement. The learning collaborative is designed for professionals who are ready to implement reflective supervision within their programs and begin the process of becoming IMH-Endorsed® in relationship-based, culturally competent practices.

The WI-AIMH Reflective Supervision Learning Collaborative (RSLC) is a 12-month process comprised of in-person learning sessions, and active implementation phases, with built-in support throughout the process. It is critical that participants be fully prepared to commit to all components of the training, as it will reinforce successful implementation and sustainability of reflective practices within your program and strengthen the overall investment of time and resources made to participate in the program.

Before completing the application make sure you carefully read the full announcement and Frequently Asked Questions (FAQ’s) to gain a full understanding of the requirements and commitment.

Please answer all of the questions in the application, which will help us to understand your background and training needs, as well as expedite the application review process. It will take approximately 30 minutes to complete the application.

Completed applications are due by February 1, 2018.

Applications will be processed in the order in which they are received.

The FAQ can be found at http://wiaimh.org/rslc-faq

1. Personal Information
Name (First, Last): *
Your answer
Title or Role *
Your answer
Agency Name *
Your answer
Agency Address *
Your answer
City and County *
Your answer
Telephone Number *
Your answer
E-Mail *
Your answer
2. What service sector does your program or agency represent? (Please select the response that best applies to you.) *
3. Does your agency specifically provide direct, relationship-based services to infants/toddlers ages birth to 36 months and their families? *
4. Do you hold a Master's degree? (Required component to be provider of reflective supervision for IMH-Endorsement® purposes) *
5. Did you complete the UW-Madison Infant, Early Childhood, and Family Mental Health Capstone Certificate Program? *
6. Have you completed FAN training? *
7. Do you supervise professionals who provide direct, relationship-based services to children ages 0-36 months and their parents/caregivers? *
8. How many staff members do you supervise? *
Your answer
9. Currently, within your role at your agency, do you provide direct, relationship-based services to children ages 0-36 months and/or their caregivers/parents? *
10. In previous roles, prior to being a supervisor, did you provide direct, relationship-based services to children ages 0-36 months and their caregivers/parents? *
If you selected "other," please explain:
Your answer
11. How much experience do you have with reflective supervision? *
12. Have you provided individual or group reflective supervision in your current or previous roles? *
Please describe your experience(s) with providing reflective supervision (optional):
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms