Traumatology Institute (Canada) Training & Development Inc.

 

 

APPLICATION FOR CERTIFICATE OF COMPLETION: 

Certified (aka Clinical); Community & Workplace, Field Traumatologist & Compassion Fatigue Specialist Designations

& Review of Tramscript Application (Equivalency Review)

 

The criteria for earning certification as a Traumatologist are outlined below (check desired certification stream):

oField Traumatologist:  Completion of 1001.  Document 20 hours of supervised practicum plus 100 hours of face-to-face contact with traumatized individuals; Application for Field Traumatologist.

oCertified (aka Clinical) Traumatologist:  Traumatology 1001 – 1005.  Document 20 hours of supervised practicum (i.e., Traumatology 1005) plus 100 hours of face-to-face contact with traumatized individuals; Application for Certified Traumatologist.

oCommunity & Workplace Traumatologist:  Traumatology 1001 – 1005.  Document 14 hours of supervised practicum (i.e., Traumatology 1005) plus Application for Community/Workplace Traumatologist.

o Compassion Fatigue Specialist:  Accelerated Recovery Program Clinician training.

 

In some cases, individuals have completed course work (i.e., training workshops and seminars) and practical experience (practicum) in the field of traumatology that are similar enough in content to Institute courses and therefore meet criteria for equivalency.  You may apply for certification or equivalency by completing all sections of this application form and attaching the appropriate documentation.  Educational requirements need to be accompanied with a course syllabus/agenda and transcript/certificate showing course completion.  The 100 hours of practice and the hours of supervision may be documented in one of two ways:  1) by submitting a letter or other relevant document from the organization(s) with which one has performed the hours or 2) having your supervisor complete the appropriate section in the “Review of Transcript” form.  In either case, a copy of the applicant’s curriculum vitae should be included.  There is a processing fee of $35 for each application.

 

CFS/C&W/CT/FT Certificate of Completion APPLICATION FORM

DATABASE REGISTRY INFORMATION

For inclusion in the Traumatologist Database please complete the following information:

           

Professional Background

1.  Are you professionally engaged in reducing emotional trauma in others?   Yes    No  (describe): ____________________________________________________________________

_____________________________________________________________________________

 

2.  Please list your current occupation: ______________________________________________

Professional designation: _________________________________________________________

Job title/organization: ____________________________________________________________

 

3.   Please list all relevant academic degrees received and date:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 

4.   Please list all relevant licenses/certifications held:

_____________________________________________________________________________

_____________________________________________________________________________

 

5.  What types of traumatic experiences have you worked with (circle all that apply)?

Natural disasters           Work-related Accidents                       Emergency Room        

Veterans                       Automobile/Boat Accidents                  Compassion Fatigue    

Kidnappings                 Airplane/Train Accidents                       Terrorism                    

Fires                             Physical Violence/Shootings                  Death and Dying

Domestic Violence        Suicide                                                 Civilian War Trauma                

Sexual Abuse               Civilian War Trauma                             Dissociative Disorders

Others: _______________________________________________________________________

 

6.  What types of populations have you worked with (circle all that apply)?

Children                       Refugees                                              Perpetrators    

Adults                          Terminally Ill                                         Elderly             

Families                        Emergency Service Professionals          Mental Health Professionals     

Minorities                     Health Care Professionals                     Veterans                                   Clergy 

Others: _______________________________________________________________________

 

7.  How long have you been doing this type of work? __________________________________

 

8.  Do you intend to apply for further certification through the Institute?  Yes      No      

 

9.  Personal Statement:  Please provide us with a brief statement (approximately 3 – 5 sentences) about your professional skills, experience, and areas of expertise (add space as needed).

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

REVIEW OF TRANSCRIPT

 

Traumatology 1001 ~ Fundamentals of Field Traumatology (3-1/2 days)

This course focuses primarily upon on-site post-trauma responding from the perspective of both emergency responders and mental health professionals.  Participants learn the fundamentals of traumatology, including the basics of thanatology, victimology, traumatic stress, stress research, crisis intervention, and debriefing models.  Class members are guided in post-trauma preparedness, planning and on-site competency building.

 

I have acquired equivalency for Traumatology 1001 as follows:

Traumatology 1001 - Overview of Traumatology               

Successfully completed course at licensed training site.  Indicate date: _____________________

Name of training site & city/state: __________________________________________________

Received equivalency.  Approved by/date: ___________________________________________

OR Applying for equivalency – documentation enclosed.

Course Name: _________________________________ Date Completed: __________________

Educational Institution: __________________________________________________________

Address: ______________________________________________________________________

Contact Name: ______________________________ Phone Number: _____________________

 

oEnclosed is a copy of my transcript/certificate that reflects my completion of this course.

oEnclosed is a copy of the course syllabus.

Comments:

_____________________________________________________________________________

 

Traumatology 1002 – Treatment Approaches (1 day)

This review of clinical treatments in the field of traumatology covers research, theory and practice information so that the traumatologist can treat clients appropriately.  Ethics, treatment approaches, assessment materials and compassion fatigue are discussed and applied to the treatment of traumatic stress.  Participants learn to conduct informal assessments that could contribute to a professional diagnosis, to distinguish between normal and aberrant behavior, to handle cases with great skill, and to have minimal negative impact upon the client and family.

 

I have acquired equivalency for Traumatology 1002 as follows:

Traumatology 1002 - Overview of Clinical Treatments      

Successfully completed course at licensed training site.  Indicate date: _____________________

Name of training site & city/state: __________________________________________________

Received equivalency.  Approved by/date: ___________________________________________

OR Applying for equivalency – documentation enclosed.

Course Name:  _________________________________ Date Completed: _________________

Educational Institution: __________________________________________________________

Address: ______________________________________________________________________

Contact Name: ______________________________ Phone Number: _____________________

 

oEnclosed is a copy of my transcript/certificate that reflects my completion of this course.

oEnclosed is a copy of the course syllabus.

Comments:

_____________________________________________________________________________

Traumatology 1003 – Contextual Applications (1 day)

One of the Traumatology Institute’s most important goal is to empower the community, the family, the company, and the individual.  This course deals with the social work and case management associated with fitting the client with treatment.  It examines age, gender, race, culture, social class, community standards of care, and other factors that are important in designing and implementing a treatment program that fits the needs of the client perfectly and concludes the program at the request and needs of the client.

 

I have acquired equivalency for Traumatology 1003 as follows:

Traumatology 1003 – Contextual Applications

Successfully completed course at licensed training site.  Indicate date: _____________________

Name of training site & city/state: __________________________________________________

Received equivalency.  Approved by/date: ___________________________________________

OR Applying for equivalency – documentation enclosed.

Course Name:  _________________________________ Date Completed: _________________

Educational Institution: __________________________________________________________

Address: ______________________________________________________________________

Contact Name: ______________________________ Phone Number: _____________________

 

oEnclosed is a copy of my transcript/certificate that reflects my completion of this course.

oEnclosed is a copy of the course syllabus.

Comments:

_____________________________________________________________________________

 

Traumatology 1004 – Trauma Treatment Skills OR

                                                                        Tools for Trauma: CBT Approach (2 days)

In this course, participants meet the comprehensive training requirements in one of the approved treatment approaches.  These include, but are not limited to, Critical Incident Stress Management/Debriefing (CISM/D), Cognitive Behavioral Therapy (CBT), Traumatic Incident Reduction (TIR), Eye Movement Desensitization and Reprocessing (EMDR), and Time-Limited Trauma Therapy (TLTT).  Each protocol must meet the following criteria: No Harm Criterion, Replication Criterion, Client Satisfaction Criterion, Placebo Criterion, and Field Test Criterion.

 

I have acquired equivalency for Traumatology 1004 as follows:

Traumatology 1004 – Trauma Treatment Skills OR Tools for Trauma: A CBT Approach

Successfully completed course at licensed training site.  Indicate date: _____________________

Name of training site & city/state: __________________________________________________

Received equivalency.  Approved by/date: ___________________________________________

OR Applying for equivalency – documentation enclosed.

Course Name:  _________________________________ Date Completed: _________________

Educational Institution: __________________________________________________________

Address: ______________________________________________________________________

Contact Name: ______________________________ Phone Number: _____________________

 

oEnclosed is a copy of my transcript/certificate that reflects my completion of this course.

oEnclosed is a copy of the course syllabus.

Comments:

_____________________________________________________________________________

Traumatology 1005 ~ Supervised Practicum (20 hours)

In this clinical practicum, participants actually practice and demonstrate proficiency in clinical traumatology skills under the supervision of a Certified Traumatologist of the Traumatology Institute.  Participants are responsible for successfully completing 100 face-to-face hours of clinical practice with traumatized individuals, families and/or communities, plus 20 hours of supervision.  Traumatology 1005 covers these 20 supervised hours.

 

I have acquired equivalency for Traumatology 1005 as follows:

Traumatology 1005 ~ Supervised Practicum (20 hours)

Successfully completed course at licensed training site.  Indicate date: _____________________

Name of training site & city/state: __________________________________________________

Received equivalency.  Approved by/date: ___________________________________________

OR Applying for equivalency – documentation enclosed.

Course Name:  _________________________________ Date Completed: _________________

Site/Name of Organization: _______________________________________________________

Address: ______________________________________________________________________

Dates of Supervision: ______________________ Total Hours: ___________________________

Contact Name: _________________________________ Phone Number: __________________

 

oEnclosed is a copy of my transcript/certificate that reflects my completion of this course.

oEnclosed is a copy of the course syllabus.

Comments:

_____________________________________________________________________________

 

Briefly describe work completed to fulfill this requirement (attach additional sheets as needed)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 

This section is to be completed by the supervisor:

Name: ________________________________________________________________________

Site/name of organization: ________________________________________________________

Address: ______________________________________________________________________

Phone #: ________________ Fax #: _________________ E-mail: ________________________

 

Are you a Certified Traumatologist with the Traumatology Institute? q Yes       q No

If not, please describe how you have fulfilled equivalency, based on the educational/experience requirements outlined above and attach a curriculum vitae (attach additional sheets as required).

_____________________________________________________________________________

_____________________________________________________________________________

 

I have supervised the work of the individual named in this application described above:

_______________________________________________  ________________________

Signature                                                                                  Date

 

Comments:

_____________________________________________________________________________

Traumatology Practicum (100 hours)

Participants are responsible for successfully completing 100 face-to-face hours of clinical practice, involving direct contact with traumatized individuals, families, and/or communities.  In addition to this, participants must have 20 hours of supervision - see Traumatology 1005.

o I have enclosed a letter from the organization(s) with which I worked.

o I have acquired the 100 face-to-face contact hours as follows:

 

Site/name of organization: ________________________________________________________

Address: ______________________________________________________________________

Phone #: ________________ Fax #: _________________ E-mail: ________________________

Dates of work: __________________________________________ Number Hours: __________

 

Site/name of organization: ________________________________________________________

Address: ______________________________________________________________________

Phone #: ________________ Fax #: _________________ E-mail: ________________________

Dates of work: __________________________________________ Number Hours: __________

 

Site/name of organization: ________________________________________________________

Address: ______________________________________________________________________

Phone #: ________________ Fax #: _________________ E-mail: ________________________

Dates of work: __________________________________________ Number Hours: __________

 

o     I have enclosed detailed documentation of the 100 face-to-face contact hours.  Examples of documentation include a letter from the organization you worked at (confirming dates and total hours) and sample field notes (omit names so as not to compromise confidentiality). 

 

Briefly describe the work you did to fulfill this requirements (add additional sheets as required):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CODE OF ETHICS

 

As Traumatologists certified with the Traumatology Institute we are committed to the following ethical principles in our work with individuals, groups and communities who experience trauma in its many forms.  In addition, we have a dedication to each other as a supportive collegial network respecting all our levels of experience and training.

 

Principle I:  Respect for the Dignity of Persons

As trauma responders, we have an abiding respect for individuals who are experiencing devastating traumatic events in their lives.  We are committed to recognizing the inherent dignity that people possess, with all the personal, social, spiritual and cultural diversity present in our society.  We make every effort to provide interventions with respect to the dignity of those we serve as a primary ethical commitment.  It is not our right to judge others, but rather assist them to understand, and ultimately come to terms with, the devastating events they have experienced.

 

We are dedicated to helping individuals, groups, and communities build on their unique strengths; to help enhance their coping skills, and, in the best possible time, to encourage their strengths so that they can become self reliant and independent.

 

Principle II:  Responsible Caring

Traumatologists certified with the Traumatology Institute are dedicated at all times to approaches that are caring, compassionate, and positive.  This commitment requires a dedicated sense of responsibility to those we serve.  The requirements and interests of others are paramount in our work.

 

We have an essential commitment to extend our caring to colleagues and ourselves.  We support our colleagues in their work and interventions and are available as involved colleagues when our own members need help.

 

Our dedication is to a collegial atmosphere of nonjudgmental support for our colleagues.  We ensure that we remain personally healthy as trauma responders, and contribute in supportive ways to our own well being as we intervene and provide interventions. 

 

We are committed to engage in proactive self-care and ongoing support and education.

 

Whether we are part of a peer debriefing team, individual trauma counselors, members of a community disaster response team, or members of a victim assistance group, we are committed to being available and providing cooperative support and help with issues of personal stress associated with trauma interventions and counseling.

 

We engage in mutual support and continuing education in all the appropriate areas of trauma response, not only to remain current and enhance our training but also to ensure that our interventions are appropriate and up to date, and that we are engaged in healthy self-care.

 

Principle III:  Integrity in Relationships

We are dedicated to a strong sense of integrity in the relationships we develop with the traumatized individuals and groups to whom we provide interventions, including ourselves.  As trauma responders we have a duty to be forthright in all our actions and behavior. It is our responsibility to ensure that we present accurately in terms of our competence in training, knowledge and credentials.  We are not to misrepresent qualifications and levels of competence.  We make every effort to extend respect to others, at all levels in our society, and with any organization.  We ensure that the right of confidentiality and privacy is actively maintained for those we serve.  We have a positive attitude about the well being of others to the point where we are confident that our interventions “do no harm,” as we engage in providing help and interventions.

 

We hold fast to the Commitment of Confidentiality as a guiding principle in the interventions we provide.  We are not afraid to indicate that we do not have all the answers and we are open and willing to learn.

 

We ensure that we refer traumatized individuals to the appropriate resources, providing ongoing liaison support for those who need it until additional support can be obtained.

 

We avoid, and exercise due caution whenever we find ourselves in, dual relationships with victims of trauma or those needing interventions.  For example, we refer family members and personal friends to colleagues rather than provide interventions ourselves.  Within organizations we ensure confidentiality for those we help and do not engage in practices that interfere with their right to privacy, respect and dignity.

 

Principle IV:  Responsibility to Society

The Traumatology Institute is founded on the belief that as Traumatologists we are committed to responding to the needs of society at all levels, from individual events to the needs of traumatized groups and communities.  In addition, we are committed to meeting the needs of our members in the areas of continuing education.  Our ethical goal is a strong commitment to a mutually supportive group of colleagues who can bring trauma response skills and intervention strategies to people all over the world as the need arises, with a sense of responsibility to the people we wish to serve.

 

Each of us has something to contribute and provide in the area of interventions.  People all over the world experience trauma in all its forms.  As Traumatologists responding to traumatic events, we are dedicated to meeting the needs of our Society in a forthright ethical manner.

 

As Traumatologists, we dedicate our responses to providing appropriate support for individuals and community, to enhance the social fabric, and for the ultimate good of the societies in which we live as well as those around the world.

 

V.         Disclaimer of Liability

I am applying for certificate of completion through the Traumatology Institute.  I understand that earning the designation of Traumatologist means that I have fulfilled the requirements established by the Traumatology Institute (Canada).  I also understand that certification of completion in no way implies that the Traumatology Institute (Canada) is liable for my actions in delivering traumatology-related services.

 

VI.       Signature

I have completed this application accurately and truthfully, to the best of my knowledge.  I have read the Traumatology Institute’s Code of Ethics and agree to abide by its principles in my work as a Traumatologist.  I have read the Disclaimer of Liability and agree to it.

 

Printed Name: _________________________________________________________________ 

Signature:  __________________________________________ Date _____________________

APPLICATION - METHOD OF PAYMENT

 

Please mail completed application, curriculum vitae, letters of reference, all support documentation and a $35 fee, made payable to Psych Ink Resources (use the Psych Ink Resources address below):

 

o     Cheque or Money Order (made payable to Psych Ink Resources)

o     Credit Card (only VISA & MasterCard accepted at this time)

 

CREDIT CARD #: __________________________________ Expiry Date: ________________

 

Signature: _____________________________________________________________________

 

Please feel to contact us directly if you have any questions.

 

Sincerely,

 

 

 

A. B. Baranowsky, Ph.D., C.Psych.,  Executive Director

 

Traumatology Institute