PCP Facilitator Resource Listing Application

PCP Facilitator Resource Listing Application

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12 Characters
1 Uppercase letter
1 Lowercase letter
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1 Special character

First Name

Last Name

Email

Which county do you live in?

Public Phone Number (to list on our website)

Mobile phone number (where we may reach you if needed)

Organization Name (optional)

Website (if applicable)

What are your method(s) of facilitation?

In personOnlineHybrid

I provide in person PCP Facilitation in the following counties: (select all that apply)

Adams	Asotin	Benton	Chelan
Clallam	Clark	Columbia	Cowlitz
Douglas	Ferry	Franklin	Garfield
Grant	Grays Harbor	Island	Jefferson
King	Kitsap	Kittitas	Klickitat
Lewis	Lincoln	Mason	Okanogan
Pacific	Pend Oreille	Pierce	San Juan
Skagit	Skamania	Snohomish	Spokane
Stevens	Thurston	Wahkiakum	Walla Walla
Whatcom	Whitman	Yakima

What type(s) of payment will you accept? (select all that apply)

DDA Waiver ServicesFee for serviceSliding feeOther

Other type(s) of payment accepted

Do you have a HS Diploma or GED?

YesNo

Do you have post-secondary education?

YesNo

What kind?

Vocational training or certificateAssociate degreeBachelor's degreeMaster's degreeDoctoral degree

Do you identify as a member of any specific communities? (i.e. Disability/Self-Advocate; Hispanic or Latino)

YesNo

Do you identify as a member of any of the following communities? (select all that apply)

Black/African AmericanIndigenous/Native American/Native Alaskan/Native HawaiianHispanic or LatinoLGBTQIA2S+Disability/Self-AdvocateFamily Member/KinOther

Other community(ies)

Have you completed PAVE's Free Online PCP Facilitation Training?

YesNo

Access PAVE's free online training.

Are you available to serve as a mentor and host a shadowing opportunity for a new PCP facilitator?

YesNo

How many years of experience do you have in Person-Centered Planning facilitation?

No experienceLess than 1 year1-3 years4-7 years8+ years

Are you an active member of a PCP Cohort?

YesNo

Please indicate which Cohort you are an active member of:

Are you affiliated with any other professional organizations related to Person-Centered Planning or disability services?

YesNo

Please indicate which professional organizations related to Person-Centered Planning or disability services.

I have completed an initial background check, and I comply with DDA Policy 5.01 timelines for renewal background checks. I attest to having no disqualifying results that would prohibit me from unsupervised access to a DDA Client

YesNo

Ages served (select all that apply)

Children/Youth (Birth through 17 years)Adults (18 through 59 years)Older Persons (60+)

Do you have experience working with specific populations? (Check all that apply)

Individuals with I/DDIndividuals with mental health needsIndividuals experiencing homelessnessIndividuals with substance use disorderVeteransLGBTQ+ individualsOther (please specify)None of the above

Other individuals

Select any skills or strengths you have (check all that apply)

Graphic Art Training/AbilitiesPerson with a disabilityPerson with a special healthcare needLived experience with historically marginalized social membership groupsDisability Specific TrainingCultural CompetencyOther

Other skills/strengths: please list

Do you have experience with any of the following specialized PCP tools or frameworks? (Check all that apply)

MAPSPATHEssential Lifestyle PlanningCharting the LifeCourseLife Domains FrameworkOther (please specify)

Other tools/frameworks

Do you speak any language(s) in addition to English?

YesNo

Which language(s)? (Select all that apply)

SpanishASLOther

Other language(s)

Anything else you want us to know about you?

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