CISN Application

Step 1 of 7

CISN Application

Thank you for your interest in joining the Critical Incident Support Network. Please complete the following application in full. Incomplete applications may not be considered. All submitted information will be kept confidential.

Personal Information

Full Name(Required)

First Middle Last

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Date Of Birth(Required)

Email(Required)

Preferred Contact Email

Cell Phone(Required)

Preferred Contact Phone Number

Home Phone

What Is your current role?(Required)

Full Time First Responder

Part Time First Responder

Retired First Responder

Chaplain

Behavioral Health Professional

Spouse/Companion of First Responder

Clarification for Behavioral Health Professionals:

Individuals who are trained to provide counseling and / or therapeutic interventions. This includes Level 2 Community Behavioral Health Liaisons (CBHLs) and licensed behavioral health professionals who have been vetted for their suitability to work with first responders. These professionals are trained to address the unique emotional, psychological, and behavioral challenges faced by individuals in high-stress, trauma-exposed occupations. They are equipped to help first responders cope with the effects of critical incidents, trauma, and the cumulative stress associated with their work. They offer individualized treatment, crisis intervention, and long-term support to promote mental well-being and resilience within the first responder community.

Do you meet this requirement?

Yes

Thank you for your interest. Please consider applying if you meet these criteria in the future.

This includes:

- Level 2 Community Behavioral Health Liaisons (CBHLs) who are part of the Missouri State Highway Patrol DEFENSE program, and
- Licensed behavioral health professionals (e.g., LPCs, LCSWs, psychologists, etc.)

Department / Supervisor Contact

Supervisor's Name(Required)

Prior Supervisor If Retired

First Last

Supervisor's Title(Required)

Supervisor's Email(Required)

Supervisor's Phone(Required)

Training, Certifications and Licensures

List of relevant training to Critical Incident Stress Management, peer support services, behavioral health training and education, ministerial training and education, and related courses.(Required)

Upload Certificates

Upload your applicable licensures, certifications, and education / training certificates. For example, POST License or Commission Card, Behavioral Health licensure, Ordination or Ministry License, Missouri Fire Fighter Certification, and Missouri EMS license.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 100 MB.

Employment History

List Your Relevant Employment History(Required)

Job Title

Employer Name

Dates Of Employment

Brief Description Of Responsibilities

Describe Your Relevant Experiences(Required)

If first responder/chaplain/clinician, describe your duties. If spouse/companion, share relationship duration & relevant experiences

Peer Support or Volunteer Experience(Required)

List past involvement in mental health education, stress management or peer support services, or related areas.

Personal Statement(Required)

Please tell us why you want to join the Critical Incident Support Network. (3–5 sentences)

Have You Ever Been Convicted Of A Felony?(Required)

Please Explain(Required)

ALL FRPN SERVICES ARE 100% CONFIDENTIAL*

Delays or difficulty selecting a provider?