Department of Counselor Education P & I Clinical Site Development Site Information Form

Transcription

1 Department of Counselor Education P & I Clinical Site Development Site Information Form Instructions for the Site Representatives: Please type your responses to the following questions in the fields provided. Use the tab key to move between fields. Please fax to (352) or mail to the following address: Kathleen M. Fallon, Ph.D., Clinical Coordinator; Department of Counselor Education; 1215 Norman Hall; POB ; Gainesville, FL If you have questions, please contact Dr. Fallon at (352) , Ext. 228 or kfallon@coe.ufl.edu. Agency Demographic Information Agency Name Mailing Address City State Zip Code Physical Address City State Zip Code Directions to Site Days and Times Facility is Open for Students to See Clients Phone Fax Website Primary Site Host Demographic Information Name Job Title Highest Earned Degree License No University of Florida Employee Work Phone Profession SSN (Required for Tuition Waiver) Work Work Fax P & I Clinical Documentation Site Information Report Revised 8/05 SIForm.doc Page 1 of 3

2 Alternate Site Host Demographic Information Name Job Title Highest Earned Degree License No University of Florida Employee Work Phone Profession SSN (Required for Tuition Waiver) Work Work Fax Clinical Information Please provide a brief description that would help introduce your site to students. Select the appropriate level(s) of experience for students at your site. Practicum Internship Select the appropriate clinical specialization(s) for students at your site. Mental Health Counseling Marriage & Family Counseling School Counseling & Guidance Identify any prerequisite coursework or clinical experiences you require of students. Minimum semester commitment Maximum number of students per semester Identify and describe characteristics of population receiving services at your site Identify counseling modalities used at your site Identify and describe professional development opportunities available at your site. P & I Clinical Documentation Site Information Report Revised 8/05 SIForm.doc Page 2 of 3

3 Clinical Supervision, Observation, and Taping Opportunities Select the clinical supervision opportunity(ies) that are available at your site. None Individual Group Students are required to tape their work for supervision. If taping is not possible at your site, students must be observed for the equivalent number of sessions. Is taping allowed at your site? Check all that apply. Select all available recording equipment No Yes-Audio Yes-Video Audio Video Students must provide own equipment Select if observation of other professionals in practice is available. Application Process Describe application instructions, including contact names and information. Yes No Do you offer financial compensation to practicum and Yes No internship students? Steps to becoming and maintaining an active clinical site with the Department of Counselor Education Step Completed Date Completed Complete and submit Site Information Form annually or whenever Site Host changes Submit current Resume or Curriculum Vita for each Site Host Schedule a Site Visit or telephone Site Visit annually with the Clinical Coordinator Current Site Information Form Form completed by Date completed Thank you for your interest in working with our Department and Students! Please print form and send to Clinical Coordinator. Questions? Contact Dr. Fallon at , Ext. 228 or kfallon@coe.ufl.edu. Dr. Kathleen M. Fallon Clinical Coordinator Department of Counselor Education 1215 Norman Hall POB Gainesville, FL P & I Clinical Documentation Site Information Report Revised 8/05 SIForm.doc Page 3 of 3

4 Robert N. Brown M.A. CAP Country Lake Drive Tampa, Florida (813) Present Director of Clinical Services and Program Development Tampa Crossroads, Tampa, Florida As the Clinical Director of all Tampa Crossroads, Inc. Residential and Nonresidential treatment programs, I provide weekly qualified supervision to clinical staff and interns, facilitate treatment team meetings, coordinate and provide trainings for staff, ensure program compliance with DCF and DOC licensure and contractual standards, and provide substance abuse and mental health counseling services to a small number of clients (5 to 8) weekly. Program Development duties include identifying and securing funding to maintain and grow our existing treatment programs through writing of grants, developing partnerships with referral sources, and identification of needed treatment services (service gaps) within the community and developing new programs to meet those needs Director of Non-Residential Services Tampa Crossroads, Tampa, Florida Supervised a department that provides all of the agency s Outpatient and Aftercare counseling services. Developed and maintained department budget and purchasing procedures. As the agency s grant writer, my duties include identifying potential funding sources, writing grant proposals, and grant management. I developed and implemented treatment programs producing over $1 million in revenue to include the J.A.D.E and P.R.I.D.E. Prostitution Programs, the M.I.P. Drug Assessment and Intervention Program, the Community Transition Program, the Men s Criminal Offender Intervention Program, and the TRIAD Habitual DUI Offender Program. In addition to my duties as Program Director, I continued to maintain a clinical caseload of 10 outpatient substance abuse and mental health clients, facilitated the Tampa Crossroads Aftercare Program, performed assessment, group and individual counseling, case management, and advocacy to the courts Primary Substance Abuse and Mental Health Counselor Tampa Crossroads, Tampa, Florida Provided individual and group therapy to clients with substance abuse or cooccurring disorders. Maintained caseload of approximately 20 clients at all times. Conducted psychosocial assessments, developed treatment plans, served on a multi-disciplinary treatment team, attended treatment team meetings, and provided referrals for employment, housing and other case management needs. Maintained clinical documentation in compliance with licensing regulations

5 Medical Office Nurse Weiss and Newberry Medical Associates, Melbourne, Florida Performed office nursing duties at a fast paced/high volume Neurology office, associated Neuro-Testing/MRI center, and Chronic Pain facility. Added duties included being OSHA Compliance officer for entire facility and conducting in office OSHA training for all employees. Education M.A. University of South Florida Rehabilitation and Mental Health Counseling B.A. University of South Florida 1999 Psychology/Chemistry, Magna Cum Laude A.A. Brevard Community College 1997 Pre Med, Summa Cum Laude Nursing Degree/LVN Maric College 1992 High Honors Licensure: State of Florida Certified Addiction Professional

6 Curriculum Vitae Gregg J. Armstrong LMHC, CAP, CCJAS N. Armenia Ave. #2206 Tampa, Fl Qualifications Masters degree in Rehabilitation and Mental Health Counseling, State of Florida Certified Addictions Professional, Licensed Mental Health Counselor, Certified Criminal Justice Addictions Specialist. Over ten years experience with addictions, personality disorders, with criminal offenders and noncriminal offenders in residential and outpatient settings. Experienced in marriage and family counseling, adolescent and preadolescent behaviors. Utilized as an expert witness for testimony of the psychological condition and forensic evaluation, during client's judicial appearences. Qualified as a clinical supervisor. Professional Experience Private Practice, Tampa, Fl. September 5, 2001 to Present Primary functions include individual counseling, assessment and evaluation of forensic and non-forensic clients and treatment planning. Clientele include dually diagnosed, anger management, domestic violence, drug and alcohol abuse/dependence, relationship counseling, impulse disorders, and personality disorders. The treatment of Axis II disorders and syndromes including Antisocial, Narcissistic, Depressive, Dependent personalities in addition to Obsessive-Compulsive disorders. Mood and Anxiety Disorders including Postraumatic Stress and all other Axis I diagnoses. Clinical syndromes such as Major Depression and severe personality pathology, including Borderline personality and Bipolar Disorder are areas of clinical experience. Area of specialization is treatment of personality disorders and forensic evaluation of criminal offenders to determine a cause of behavioral patterns and develop a plan of treatment and long term goals to reduce recividism. Facilitation of group counseling for felony and first time criminal offenders as ordered by the court. Director of Non-Residential Services, Tampa Crossroads Inc., Tampa, Fl. August 10, 2000 to August 10, 2001 Primary responsibilities were overseeing and facilitating the aftercare program, individual outpatient counseling of criminal offenders, marriage and couples counseling. Additionally, acted as a liaison for the Florida Department of Corrections, the Criminal Justice System and court ordered clients. Other duties included assessment and evaluation for the Misdemeanor Intervention Program, monthly reporting to the Department of Corrections, forensic assessment and evaluation, treatment planning, updating and maintaining records. Client Manager, Turning Point of Tampa, Tampa, Fl. February 21, 1997 to August 8, 2001 As client manager, my responsibilities included overseeing the Eating Disorders and addiction issues, client community. Participation in and facilitation of process group for disorder clients, crisis intervention and conflict resolution. Other duties included medication monitoring, assessment, intake and behavioral charting. Education Bachelors Degree from the University of Florida, Philosophy. August, 1980 Masters Degree from the University of South Florida, Rehabilitation and Mental Health Counseling. December, 2001 Continuing Education Adolescent Chemical Dependency, January, 2003 Clinical Supervision Training, October, 2003 Aggression and Violence: Understanding and Managing the Psysiology and Psychology of Emotional Rage. August, 2004 Trauma and Personality Disorders. October 2004 Substance Abuse Prevention for the 21st Century. June, 2005 Medical Errors. January, 2006 Domestic Violence. January, 2006 Professional Ethics and Boundary Issues. January, 2006 Dual Disorders, June 2006 Addictions and Co-Existing Conditions, July 2006 Response to Trauma, Neglect and Abuse, July, 2006 Certification and Licensing: Licensed by the State of Florida as a Licensed Mental Health Counselor ( LMHC ) December, 2003

7 State of Florida Certified Addictions Professional ( CAP ) April, 2001 National Association of Forensic Counselors, Certified Criminal Justice Addictions Specialist ( CCJAS) July, 2004 Forthcoming publication; "Early Truma and Subsequent Adult Antisocial Behavior in Adults".