Co-occurring Disorders Train the Trainer TIP #42
September 10-12, 2008
Albany, NY
Nominee Application
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You have been nominated to apply for participation in a training to prepare trainers to teach others about the treatment of Co-occurring Disorders. This training is based on the TIP (Treatment Improvement Protocol) #42. We are looking for well-qualified people who have some knowledge of the TIP #42 and significant training delivery and treatment experience for both mental health and substance use disorders. Please take a few minutes to complete this brief application and read and sign the contract on the following page.
Applicant Information – Please complete information for your home address.
| Name: | |||
| Street Address: | Home Phone: | ||
| City/State/Zip: | Home Email: | ||
| County: | |||
Employment Information
| Job Title: | |||
| Employer Name: | Employer County: | ||
| Street Address: | Work Email: | ||
| City/State/Zip: | Work Phone: | ||
Work Setting:
- CD Inpatient/Residential
- Outpatient CD
- CD Detox/Crisis Center
- Outpatient MH
- MH Inpatient/Residential
- Methadone
- Other:__________________________
Professional Information (check highest level of education and attach supporting documentation):
Education:
- GED
- High School
- Associate's
- Bachelor's
- Master's
- Doctoral or higher
Current Credentials or Licenses (check all that currently apply to you and submit supporting documentation):
- CASAC
- Gambling Credential/Certification
- Psychologist
- LMHC
- CPP/CPS
- Physician
- Rehabilitation Counselor
- LCSW/LMSW
- Physician's Assistant
- Occupational Therapist
- Since this is a Train the Trainer program, there is an expectation that applicants have significant experience training chemical dependency and mental health professionals. For instance, a qualified candidate might have completed a Train the Trainer curricula before and have successfully delivered, coordinated and marketed, at least a day long training, to addiction and/or mental health professionals outside their normal job duties and for participants other than those at the agency of employment. Please use the space below to elaborate on your training experience similar or comparable to that described above.
- Please describe your experience in mental health and/or chemical dependency treatment settings:
- Please write a brief (200 words or less) essay explaining why you are interested in this train the trainers, what you will bring to the training and how you implement training in your community.
Agreement
If selected to participate in the Train the Trainer scheduled for September 10-12, 2008 at the Addictions Care Center of Albany, 90 McCarty Avenue, Albany, NY 12202, I agree to the following:
- Provide at least two trainings in the community for Chemical Dependency and Mental Health treatment providers within one year of completing the training.
- Participate in a learning community sponsored by the Northeast Addiction Technology Transfer Center for at least 18 months following the training.
- Co-train at least one of the two trainings with someone who is more experienced in the other discipline (if possible).
- Provide follow-up technical assistance to trainees to encourage successful dissemination of the training content and encourage implementation.
My signature attests to my commitment to the above criteria for acceptance into this training:
Signature
Date
I supervise the nominee for this training and my signature below attests to my commitment to allowing time for the nominee to fulfill this agreement:
Signature
Title
Date
Applications must be postmarked on or before August 8, 2008. Applications will be reviewed by a team of NYSOASAS and NYS Office of Mental Health (OMH) staff. Successful candidates will be notified by email on or before August 15, 2008.