REBATI Questionnaire

REBATI HAITI QUESTIONNAIRE

Asterisks indicate required fields.

Red text indicates required fields.

Personal Information

First Name: Last Name: Email: Telephone (mobile): Telephone (other): Country: State/province: City:

Spoken language fluency (check all that apply):

English French Creole

Haitian native:

Yes No

Lived in Haiti after age 12 for:

Less than a year 1-5 years More than 5 years

Choose a Password

Password: Re-type password: Security question: Your answer:

Availability

For volunteer work in Haiti, choose a maximum time commitment:

2 weeks 1 month 2-3 months 4-6 months 7 months - 1 year More than 1 year I don’t know yet

For volunteer work in your own local community outside Haiti, pick your time commitment and its duration:

Less then 5 hours a week Between 5 and 10 hours a week Between 11 to 20 hours a week More then 20 hours a week

Nature of Help

We would like to know what kind of help you can give. Please indicate all choices that apply.

I can help with translation and revision of documents from English to Creole, or English to French or Creole/French to English. I wish to offer professional help (e.g. therapy, social support, follow-up, clinical care, liaison with communities and other agencies) in Haiti. I wish to offer help in local communities. I am available for teletherapy (therapy via phone line). I am available to give conferences on the impact of the earthquake to the general public and to professionals such as clinicians, clergy, nurses, school teachers. I am able to give supervision to Haiti’s psychosocial providers by mail or phone. I would like to share my ideas or comments:

Qualifications

Please check the box that bests describe your level of training.

I am (check all that apply):

Experience

I have other experience in psychosocial interventions (e. g., community education and mobilization, facilitating social services, public health education, health advocacy).
Please describe: I have post-trauma or emergency setting training (at least approximately 16 hours of training in that field).

I have (check all that apply):

worked with mass trauma effects among local communities. worked in large-scale disasters.

specific training in posttraumatic event psychological reactions:

training in the assessment of post-traumatic reactions. Describe: training in the treatment of post-traumatic reactions. Describe: training in the assessment of depression or suicidality. Describe: training in the treatment of depression or suicidality. Describe: training in the assessment of grief. Describe: training in the treatment of grief. Describe:

Please describe more specifically your prior experience here:

How many years of work experience do you have in your profession?

Do you follow Haitian patients/clients in your clinical work?

Yes No

What language do you use with them? (Check all that apply):

Creole French English

If you are working in the field of psychology, social work or psychiatry, would you describe your work follows a particular approach (check all that apply):

Cognitive-Behavioral Interpersonal Psychoanalytic Humanistic Systemic Group Family
Other:

Have you ever given conferences or workshops on post-traumatic and stress reactions?

Yes No

Have you ever given professional help at time of disasters or conflicts?

Yes No

If so, please describe briefly your experience:

Please indicate if you are a practitioner with office space that might be donated part-time for use for focused clinics or community initiatives:

Yes No

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