Team Member Application | MetroCISM | Minnesota | Peer Support

All information provided is considered confidential and will not be shared with any person or agency not directly affiliated with The Metro CISM Team.

Please use additional paper if necessary for responses.

Section 1: PERSON INFORMATION

First Name

Last Name

Address

Email

Phone

Are you willing to use a cell phone that can receive app-based messages for private communication?

Yes

No

Do you have permission from your employer to join the CISM Team?

Yes

No

Section 2: EMPLOYMENT INFORMATION

Employment Status

Retired

Self-Employed

Employer

Position

Employer's Address

Immediate Supervisor's Name

Supervisor's Phone Number

Select the discipline that most describes your work

May we contact your employer?

Yes

No

Section 3: GENERAL QUESTIONS

1. Why do you want to volunteer with this Team?

2. What skills, leadership abilities and/or personal qualities do you possess that would make you a good CISM peer counselor and crisis interventionist?

Please cite specific examples of situations in which you have used these skills to assist a peer in a time of difficulty.

3. What experience(s) do you have in providing any of the following? Include a description of services and time spent in these areas:

A. Individual Counseling:

B. Stress Management:

C. Peer Support:

D. Training:

5. Please list all professional, social or volunteer organizations to which you currently belong:

6. The Metro CISM Team meets and provides services mainly after “normal” working hours. Are you available to respond on weekends and evenings?

Yes

No

Section 4: BACKGROUND

Have you ever been convicted of a misdemeanor, gross misdemeanor or felony?

Yes

No

If YES, please explain:

Section 5: STATEMENT

Please add any comments or additional information you would like us to know about you to aid in our selection process.

Section 6: RELEASE OF INFORMATION

Because of the sensitive issues The Metro CISM Team deals with, we request your written authorization to do background checks and follow-up with current and former employers and to verify all information provided within this application. By your signature below, you authorize The Metro CISM Team to perform due diligence in researching the information provided herein.

Signature of Applicant

Signature field is empty.

Please upload a letter of support from your present supervisor / manager / agency / judicatory.

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