Request for Assistance If you are human, leave this field blank.Name *Email *Position/Title *Work Phone *School or Agency *County *BarbourBerkleyBooneBraxtonBrookeCabellCalhounClayDoddridgeFayetteGilmerGrantGreenbrierHampshireHancockHardyHarrisonJacksonJefferesonKanawhaLewisLincolnLoganMarionMarshallMasonMcDowellMercerMineralMingoMonongaliaMonroeMorganNicholasOhioPendletonPleasantsPocahontasPrestonPutnamRaleighRandolphRitchieRoaneSummersTaylorTuckerTylerUpshurWayneWebsterWetzelWirtWoodWyomingWork AddressApt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeHave you attended the WV Early Childhood PBIS Academy? *YesNoIf yes, what year did you attend ECPBIS? *Check all that apply.2016 - 20172017 - 20182018 - 20192019 - 2020Have you attended the WV School-Wide PBIS Academy? *YesNoIf yes, what year did you attend SWPBIS? *Check all that apply.2014 - 20152015 - 20162016 - 20172017 - 20182018 - 20192019 - 2020Did you speak with someone from the TA Center before making this request?Amy CarlsonDianna Bailey-MillerErin DayMarc EllisonJennifer EverhartJessica GeorgeJim HarrisTiffany HendershotTeryl JonesAmy KellySara SmouseAlicia ZimanWVDEI am requesting technical assistance because my staff/faculty need support with: *TraumaClassroom ManagementClassroom StrategiesSelf CareChallenging BehaviorTier 2Tier 3Mental Health First AidEarly Childhood PBISSchool-wide PBISOtherOtherWhat are your desired outcomes or agency goals of the technical assistance? *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? *Early Childhood PBISSchool-wide PBISMental Health First AidLeader In MeCommunity in SchoolsProject Aware School/County Expanded School-Based Mental HealthSchool Social WorkerBehavior InterventionistSubstance Use Prevention ProgramOther: Please explainOther behavior/mental health supports *What is the targeted age range and/or grade level of students that will benefit from the technical assistance/training/professional development? *i.e. My after school staff work with students from PreK-5th grade/5-11 years oldWhat is the expected number of attendees for the training/professional development? Please describe the participants. *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? *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.? *YesNoPlease provide 3 dates when you will be available to have an initial phone consultation to discuss your request.Choice 1 *Choice 2 *Choice 3 *How did you learn about us? *TA Center StaffWVDEReClaimCounty/School AdministratorCounty Special Education DirectorConferenceRadioWebsiteOtherHow did you learn about us Other *Submit
