The Workplace Trauma Center

Crisis Responder Application

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 Contact Us.

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 corporate crisis support

If you wish to apply you may start the process by either downloading and printing our Application Form or you may fill out the online form below and submit it to us.

Our Fax Number is:
1 (410) 356-8299

Our Mailing Address is:
The Workplace Trauma Center
1311 Londontown Blvd, Suite 120 # 208
Eldersburg, Maryland 21784 USA

We will also need for you to fax or mail copies of your diploma, professional license, professional liability insurance, and critical incident or crisis management training certificates. Thank you for your interest.

Crisis Responder Application
Name:	(Required field)
Address:
City:
State:	Zip:
Country:
E-mail:	(Required field)
Work Phone:		Home Phone:
Cell Phone:		Additional Phone:
FAX:
Professional License:	State:
Degree:	ICISF Member:
CISM and Crisis Intervention Training Received:

Languages Spoken:
General Availability for Incident Response:
Daytime Weekday:
Evening Incidents:
Weekend Incidents:
I can be in Transit within 30-60 Minutes:
Choose one:

I am willing to respond to incidents involving overnight travel: Yes No
I am willing to travel internationally: Yes No
Do you have a Passport? Yes No
Please indicate Metropolitan areas within a 2 hour drive of where you live/work:

List critical incidents you have responded to in the Past two years:

List any critical incidents or disaster Mental Health Teams you are on:

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.


Please answer the following questions:
Have you ever been convicted of a crime other than a misdemeanor traffic offense? Yes No
Have you ever had a professional association, ethics or licensure board find you guilty of an ethics violation? Yes No
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? Yes No
Have you ever been placed on probation or asked to resign from a CISM team, disaster mental health team, or other crisis intervention program? Yes No
Have any of your licenses, board certifications or professional association memberships been suspended, revoked or restricted in any way? Yes No
Has your malpractice insurance ever been cancelled, suspended, restricted, limited, special rated or not renewed? Yes No
Are you currently engaged in the illegal use of drugs? Yes No
Is there any reason that you are not able to perform the essential functions of the position for which you have applied? Yes No
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? Yes No
If you answered "yes" to any of the above, please provide an explanation for each affirmative response. Contact Us.
Please FAX or mail a copy of your professional license, malpractice insurance face sheet, diploma, resume and CISM/Crisis Intervention Training Certificates to our fax number or address above.

Please enter the text you see in the image below to complete the form.

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