The Workplace Trauma Center Responder Application Form
The Workplace Trauma Center is always looking for qualified crisis responders throughout the world. Please carefully review our minimum requirements before filling out the application
If you have any questions about whether your qualifications meet our requirements please at rjo@workplacetraumacenter.com.

Minimum Requirements:

- A Masters Degree or higher in a mental health field
- A License to practice at the independent level
- Professional liability insurance
- Training in Critical Incident Stress Management preferred, but comparable training will be considered
- Experience in providing on-site workplace crisis support

Once you have submitted this form please send the following documentation to us by fax at 410 970-4529, or by email to rjo@workplacetraumacenter.com:

1. Graduate diploma
2. Professional license
3. Professional Liability Insurance verification
4. Critical Incident or crisis management training certificates

Please start the Application process by filing out the online form below and submitting it to us.

First Name
Your answer
Middle Initial
Your answer
Last Name
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip/Postal Code
Your answer
Country
Your answer
Email Address:
Your answer
Work Phone #
Your answer
Home Phone #
Your answer
Cell Phone #
Your answer
Prefered Number(s) for us to call you:
Required
Professional License
Required
State, License type, License number
i.e.: NJ, LCSW-C, 1234
Your answer
Highest Degree Earned
Training Received
List any training you have received in Critical Incident Stress Management, Crisis Management, etc.
Your answer
Languages Spoken
Availability Weekdays
Availability Evenings
Availability on Weekends
Availability for immediate response
Are you willing to travel overnight?
Are you willing to travel internationally
Do you have a valid passport?
Please list metropolitan areas within 2 hours driving distance of where you live/work:
Your answer
Please list types of critical incidents you have responded to in the past 2 years:
Your answer
List any critical incident or crisis teams you are on:
Your answer
We offer training programs to our corporate clients. If you are interested in offering training programs, please list the programs you currently are able to offer.
Your answer
Have you ever been convicted of a crime other than a misdemeanor traffic offense?
Have you ever had a professional association, ethics or licensure board find you guilty of an ethics violation?
Have you ever had privileges at any hospital, facility, or health plan, voluntarily or involuntarily surrendered, denied, suspended, revoked, restricted, limited or put on probation?
Have you ever been placed on probation or asked to resign from a CISM team, disaster mental health team, or other crisis intervention program?
Have any of your licenses, board certifications or professional association memberships been suspended, revoked or restricted in any way?
Has your malpractice insurance ever been cancelled, suspended, restricted, limited, special rated or not renewed?
Are you currently engaged in the illegal use of drugs?
Is there any reason that you are not able to perform the essential functions of the position for which you have applied?
Within the last (5) years have you been reprimanded or disciplined in any manner by any state licensing authority or professional board or peer committee for conduct related to the use of alcohol or the use of drugs?
If you answered "yes" to any of the above or if you have any questions or concerns, please enter them below:
Please use this item to make any comments or ask any questions.
Your answer
Please enter any additional information about yourself that you would like to share with us:
Your answer
I certify that all statements are correct and accurate!
You are finished! If the submit button does not work, please scroll up to find any required items that were not completed.
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