CLFC Facilitator Profile Sheet Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Email *Race *Birth Year *Preferred PronounsAccommodations or special needs necessary to facilitate, if none, please state none or n/a *CLFC Facilitator ExperiencePlease provide the name of the agency or organization you work for. If you do not work for an agency or organization, please reply independent. *When did you become certified in CLFC? (approximate is fine i.e. Fall 2023) *Have you implemented CLFC? *YesNoWhat CLFC programs have you implemented? *YouthFatherhood/ParenthoodMarriageFamily Component-Parent and Youth CombinedPlease select all that applyWhen was the last time you implemented CLFC? *Where did you last implement CLFC? *Where else have you implemented CLFC? *Correctional InstitutionsTreatment/Recovery ProgramsYouth/After-school programsLocal CommunityFaith-based InstitutionsOtherI’ve not implemented CLFC anywhere other than above.Please specify.Have you completed training in Problem, ID, and Referral (PID)? *YesNoI’m not sureAre you currently facilitating CLFC within the ODRC Partner Institutions? (often referred to as Original CIP or Family Component) *YesNoAre you interested in facilitating CLFC within the ODRC Partner Institutions? (often referred to as Original CIP or Family Component) *YesNoMaybeHave you completed the ODRC Volunteer Training? *YesNoI’m not sureThis training is mandatory for those facilitating within the ODRC participating institutions.When were you approved to facilitate within ODRC? (approximate month/year)Have you been trained in virtual meetings for the ODRC-Youth/Family Component? *YesNoAre you interested in being trained for the Virtual ODRC-Youth/Family Component *YesNoMaybeThis requires the ability to teach online using ZoomPlease select the institutions, days, and times you are available implement CLFC.Please select the ODRC Partner Institutions you are interested in facilitating CLFC. *Allen-Oakwood Correctional (AOCI)Dayton Correctional (DCI)London Correctional (LoCO)Madison Correctional (MaCI)Mansfield Correctional (ManCI)Marion Correctional (MCI)Ohio Reformatory for Women (ORW)Pickaway Correctional (PCI)Richland Correctional (RICI)Toledo Correctional (ToCI)Please select the days and times you are available to facilitate. *Mondays before 5pmMondays after 5pmTuesdays before 5pmTuesdays after 5pmWednesdays before 5pmWednesdays after 5pmThursdays before 5pmThursdays after 5pmFridays before 5pmFridays after 5pmSaturdaySundayPlease select any additional certifications or credentials you have. *CHESLICDCLife SkillsLSWLISW, or LISW-SMental Health First AidMSWOCPCOCPSOCPSAPeer Recovery SupporterQPRYouth Mental Health First AidOtherNot applicablePlease specify *Please use this space to include any additional information you would like to share.Submit