The code block below illustrates how one might use # and // as comments in your logic and calculations.

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This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

x6Ez6JcZue5iUvnw7XvhiH9EUS8ZgtkPXWWIQeo

PBS Technical Assistance / Mentoring Application

Positive Behavior Support (PBS) Technical Assistance/Mentoring provides additional guidance and support to professionals in the field of PBS by phone, email, and/or telehealth.

Eligibility Requirements

The participant must be a professional in WV that serves individuals with an intellectual/developmental disability, traumatic brain injury, and/or serious emotional disorder.

Your application will be forwarded to a member of our program who will be in touch with you as soon as a review has been conducted. Depending on the services you’re requesting, you may be sent additional paperwork for the guardian or individual to sign. If you do not hear from the program within 3 business days, please contact 855-558-4296 or pbs@hsc.wvu.edu for assistance.

If you need assistance completing this form, please call 855-558-4296.

I am seeking PBS technical assistance / mentoring as a:

* must provide value

Professional seeking help with a specific person I serve.

Professional seeking guidance with general Positive Behavior Support that will benefit multiple people I serve.

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Client's initials:

* must provide value

Behavior of Concern:

* must provide value

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Please complete the following questions as they relate to you, the requestor of services.

First Name:

* must provide value

Last Name:

* must provide value

What organization do you work for?

* must provide value

Job Title:

* must provide value

Work Phone:

* must provide value

Cell Phone:

Email Address

* must provide value

Primary County of Service Delivery:

* must provide value

How did you hear about us?

* must provide value

Do you work in any of the following services? Please check all that apply.

* must provide value

Children's Mental Health Wraparound

Children's Mobile Crisis Services

Residential Treatment including the Potomac Center

Juvenile Justice

Intellectual and Developmental Disability Waiver

Aged and Disabled Waiver

Traumatic Brain Injury Waiver

Serious Emotional Disturbance Waiver

Substance Use Disorder Waiver

None of the Above

Please provide a general explanation of your need for our services:

* must provide value

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How confident do you feel providing PBS services?

Please select a value from 0 - 10.

0 = Extremely confident
5 = Moderate amount of confidence
10 = Extremely worried and unprepared

* must provide value

0 1 2 3 4 5 6 7 8 9 10

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Are you currently WV CANS (Child and Adolescent Needs and Strengths Assessment) certified?

* must provide value

Yes

Unsure

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I have read and understand the Privacy Practices.

* must provide value

Agree

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.