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CISM Team Application

Welcome to the Lancaster County Criticial Incident Stress Management Team Membership Application!

Before applying, please review the criteria listed below:

All emergency service workers, first responders or mental health professionals who satisfy the following criteria may apply for membership:

  1. Emergency Services Workers/First Responders (Peer) – has served as a first responder for at least 1 year with substantial experience.

  2. Mental Health Responders must have advanced academic training and substantial experience in providing mental health services.

  3. All applicants will have their references checked prior to membership acceptance.

Submitting this application does not guarantee membership. As well, membership does not guarantee deployment.

 

If you have any questions regarding this survey: please contact lancastercism@gmail.com

There are 12 questions in this survey.
Demographics
(This question is mandatory)
Please select the category that applies to you
(This question is mandatory)
Please list your name.
First, MI, Last
(This question is mandatory)
Please list any Higher Education: 
Include: Institution, Degree/Major, Date Graduated. If multiple, please list all relevant experiences. 
(This question is mandatory)
Employment Information (for the last 8 years)
Include the employer, position and the date of employment.
List and describe any formal training you have received in stress management, crisis intervention, counseling or other mental health areas. 
(This question is mandatory)
Describe your emergency service experience. 
Include: organization, dates, positions and a recent supervisor's contact information. 
(This question is mandatory)
Have you ever been convicted of a criminal offense? If YES, please detail in the comment section. 
(This question is mandatory)
Describe your interest and potential contributions to the this team. 
(This question is mandatory)
Any additional information (comments or concerns)?
(This question is mandatory)
Please list three references who can support your role on this team: 
Include name, phone number and relationship
(This question is mandatory)
Please submit your Pennsylvania State Police Criminal Background Check here. If you do not have this proceed to this link here and select "volunteer". 
 Upload file
(This question is mandatory)

I understand that the completion of this application does not guarantee memebership on the Critical Incident Stress Management Team. I further attest that all information provided on this application is the truth as I know it. 

Please type your name in the box below. 

 
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