ICISF Team Information Form

                          All ICISF teams must provide the information on this form annually in order to remain on the "Current Team" list. If ICISF does not have current information on file the team may not be included in referrals in response to requests for CISM assistance.

Fill in the appropriate blanks and click on the "Submit" button when complete

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DATE     Reporting period:  to

Section (A)

Complete team name and mailing address:

Team Name      Team number (if known)

Attention       

Address       

City                 State      ZIP+4  +   Country  

County  Other counties served?

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Is your team affiliated with a "network"?  Yes  No  

Network Name   Contact Number(s)  

Is the network your principal emergency contact? Yes  No    (If "Yes" the line above should be completed)

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EMERGENCY TEAM CONTACT NUMBERS: (For toll free numbers please indicate whether "local" or "national".)

Phone  Person

Phone  Person

Routine team contact numbers: (For toll free numbers please indicate whether "local" or "national".)

Phone  Person

Phone  Person

Primary & secondary Email contacts:

Name  Email Address

Name  Email Address

Team Coordinator:

Name  Contact number(s) 

Clinical Director:

Name  Contact number(s)

Sponsoring Agency?: 

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Section (B)

Number of pre-incident (Awareness/Orientation) education programs conducted: 

Number of CISM responses:  1:1 Interventions    Defusings   Debriefings

Other (Please specify)

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Section (C)

Total number of team members:  Mental Health   Peer   Team total

MHPs at:   Doctorate level  Masters level Other (specify)

Number of peer support personnel on your team: Only one classification per person, total should equal total of team members as above.

Fire only     Rescue only     EMS only     Law enforcement only     Fire/Rescue/EMS   

 Communications/Dispatch    Nurse     Physician    Any combination of two or more categories 

Other (Specify) 

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Section (D)

Our CISM Team/Organization follows the "ICISF Model" (formerly "Mitchell Model") for interventions and team management structure.

Yes  No

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Section (E)

When evaluating your CISM team mission and its target groups, how would you classify the population that you primarily serve (more than one may be checked):

All Emergency Services    Fire Service       EMS     Fire/Rescue/EMS    Law Enforcement     Airline    Hospital Staff

 School  Private Industry    Military     Community      Other populations (specify)

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Section (F)

Are any of your team members fluent in languages other than English? Please indicate below:

Language   Mental Health  Peer  Phone consultation only?  Yes  No    Travel?  Yes  No  

Language   Mental Health  Peer  Phone consultation only?  Yes  No    Travel?  Yes  No  

Language   Mental Health  Peer  Phone consultation only?  Yes  No    Travel?  Yes  No  

Language   Mental Health  Peer  Phone consultation only?  Yes  No    Travel?  Yes  No  

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Section (G)

Sometimes ICISF receives requests from individuals or agencies that are not "Emergency Service" or "Public Safety" based. Please indicate your Team's preferences:

Our CISM Team wants to be notified for emergency service requests only.   Yes

Our CISM Team wants to be notified for all requests for assistance.   Yes  No  

We will assist non-emergency requests directly  or indirectly on a case by case basis  

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Section (H)

ICISF policy is NOT to release CISM team contact information for general non-emergency purposes unless prior approval has been obtained from the team.

Do you want ICISF to release your information:

     To any individual or agency that requests the information? Yes      No    

     To other CISM teams ONLY? 

Do not release our information to anyone:     

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Additional information/comments:

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