Request for Assistance Name(Required) First Last Email(Required) Work Phone(Required)Position/Title(Required) School or Agency(Required) County(Required)BarbourBerkeleyBooneBraxtonBrookeCabellCalhounClayDoddridgeFayetteGilmerGrantGreenbrierHampshireHancockHardyHarrisonJacksonJeffersonKanawhaLewisLincolnLoganMarionMarshallMasonMcDowellMercerMineralMingoMonongaliaMonroeMorganNicholasOhioPendletonPleasantsPocahontasPrestonPutnamRaleighRandolphRitchieRoaneSummersTaylorTuckerTylerUpshurWayneWebsterWetzelWirtWoodWyomingWork Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Have you attended the WV Early Childhood PBIS Academy?(Required) Yes No 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 No 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?Dianna Bailey-MillerAmy CarlsonErin DayMarc EllisonJennifer EverhartJim HarrisTiffany HendershotMarlo HornsbyTeryl JonesAmy KellyKate MorrisSara WinesSara WolfeAlicia ZimanWVDEI am requesting technical assistance because my staff/faculty need support with:(Required)TraumaClassroom ManagementClassroom StrategiesSelf CareChallenging BehaviorTier 2Tier 3Mental Health First AidEarly Childhood PBISSchool-wide PBISOtherOther(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) Early Childhood PBIS School-wide PBIS Mental Health First Aid Leader In Me Community in Schools Project Aware School/County Expanded School-Based Mental Health School Social Worker Behavior Interventionist Substance Use Prevention Program Other: Please explain 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 No ***Please provide 3 dates when you will be available to have an initial phone consultation to discuss your request.***Choice 1(Required) MM slash DD slash YYYY Choice 2(Required) MM slash DD slash YYYY Choice 3(Required) MM slash DD slash YYYY How did you learn about us?(Required) TA Center Staff WVDE ReClaim 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 No Please describe the student behaviors you are concerned about(Required)CAPTCHA