Request for Assistance

Name(Required)

First Last

Email(Required)

Work Phone(Required)

Position/Title(Required)

School or Agency(Required)

County(Required)

Work Address(Required)

Street Address Address Line 2 City State ZIP Code

Have you attended the WV Early Childhood PBIS Academy?(Required)

Yes

If yes, what year did you attend ECPBIS?(Required)

2016 - 2017

2017 - 2018

2018 - 2019

2019 - 2020

Have you attended the WV School-Wide PBIS Academy?(Required)

Yes

If yes, what year did you attend SWPBIS?(Required)

2014 - 2015

2015 - 2016

2016 - 2017

2017 - 2018

2018 - 2019

2019 - 2020

Did you speak with someone from the TA Center before making this request?

I am requesting technical assistance because my staff/faculty need support with:(Required)

Other(Required)

What are your desired outcomes or agency goals of the technical assistance?(Required)

i.e. Our teachers are struggling to meet the needs of the students in our building that have experienced and are living with trauma. Our goal is to become educated on how to best support those students and provide resources to families. A larger goal is to provide onsite counseling services for students and families.

Which of the following behavior/mental health supports does your school/county utilize?(Required)

Other behavior/mental health supports(Required)

What is the targeted age range and/or grade level of students that will benefit from the technical assistance/training/professional development?(Required)

i.e. My after school staff work with students from PreK-5th grade/5-11 years old

What is the expected number of attendees for the training/professional development? Please describe the participants.(Required)

i.e. I am expecting all teachers (PreK-after school staff), our behavior support specialist, and counselor to attend. I would estimate around 30 attendees.

What is the timeline for your request?(Required)

i.e. Sometime in late March beginning of April. I am flexible but would like to have the training before the middle of April.

Is this a request to present at a conference, county office, new teacher boot camp, etc.?(Required)

Yes

***Please provide 3 dates when you will be available to have an initial phone consultation to discuss your request.***

Choice 1(Required)

Choice 2(Required)

Choice 3(Required)

How did you learn about us?(Required)

TA Center Staff

WVDE

County/School Administrator

County Special Education Director

Conference

Radio

Website

Other

How did you learn about us Other(Required)

***Early Childhood Only***

Is this a Tier 3 request(Required)

Yes

Please describe the student behaviors you are concerned about(Required)

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