ࡱ> y{xi I+bjbjښ .\\#5FFFFFZZZ8\4Z)V""888OOO) ) ) ) ) ) )$+..)F|O.)FF88C)-$-$-$^F8F8)-$)-$-$ 'X'80 ;'E^$'(Y)0),',;/;/X';/FX'Oh-$ITJOOO.).)w!OOO);/OOOOOOOOO> :  AMERICAN ASSOCIATION OF SUICIDOLOGY 5221 Wisconsin Avenue NW, Washington, DC 20015 Application for Accreditation or Re-Accreditation New: Re-accreditation: ___ Date: ________ I. DATA REGARDING PROGRAM Name of Program: Contact Person: Address: City: State: Zip: Business Telephone Number: After hours number (mobile) Name of Executive Director: Email: E-mail of Contact Person:  (1) Current Annual Budget (crisis services only): (2) Is your organization a member of AAS? Yes No (If no, you must be a member of AAS to be accredited) 3) List below the name of major funding sources II. SERVICES PROVIDED: Check all services provided. Double check those considered major purposes or objectives _____ Suicide Prevention Hotline _____ General Crisis Hotline _____ Sexual Assault Counseling _____ Child Abuse Counseling _____ Teen Hotline _____ Teen to Teen Hotline _____ Survivors of Suicide Support Group _____ Drug Information Service _____ Substance Abuse Counseling _____ Substance Abuse Counseling _____ General Victim Services _____ Outreach Program _____ Face to Face Counseling _____ Mental Health I & R _____ Drop In Center _____ Domestic Violence _____ General Grief Support Groups _____ Mobile outreach _____ Compassionate Friends ______ Crisis Chat ______ Crisis Services via Text Messaging _____ Specify Other: III. PERSONNEL INFORMATION Program Directors Name: ______________________ Degree(s): _________________ Directors Employment Status: Full Time Part Time Salaried Volunteer Total Number of Paid Employees: __________Full Time: _____Part Time: _____ Total Number of Volunteers (organizational wide) _________ I have included: _________ A copy of my organizations active rescue (see accreditation manual policies and procedures.) ________ A completed Pre-Screening Questionnaire, with explanations of questions answered no. In submitting this Application for Accreditation to the American Association of Suicidology, we hereby agree to the following conditions related thereto: AGREEMENT 1. We agree to prepare and provide copies of any written material that may be requested by the Committee on Accreditation as a part of the evaluation process. 2. We agree to pay the fees required and to maintain an organizational membership in AAS. Accreditation Fees: For new organizations: $250 application fee, $2500 accreditation fee, all examiner expenses ($50 maximum/day for meals). If accreditation of Online Emotional Support is also requested please add additional fee of $250. Send application fee and accreditation fee with this form. You will be billed for the examiners expenses after the site visit. Or in the case of a virtual accreditation a $1,500 fee will be invoiced after the accreditation is complete. But no other surveyor's expenses. If multiple sites need to be accredited a separate fee will be negotiated. For re-accreditations: $1500 accreditation fee and all examiner expenses. If accreditation of Online Emotional Support is also requested please add additional fee of $250. Send accreditation fee with this form. You will be billed for examiner expenses after the site visit. Or in the case of a virtual accreditation a $1,500 fee will be invoiced after the accreditation is complete. But no other surveyor's expenses. Annual Membership Dues: (Budgets based on Crisis Services) For organizations with annual operating budgets below $100,000 the dues are $220 For organizations with budgets from $100,000 to $199,999 the dues are $270 For organizations with budgets from $200,000 to $499,999 the dues are $390 For organizations with budgets from $500,000 to $749,999 the dues are $530 For organizations with budgets from $750,000 to $999,999 the dues are $650 For organizations with budgets greater than $1,000,000 the dues are $800 3. We agree to notify the Director of Crisis Services Accreditation immediately whenever any change in our program may affect our accreditation status. 4. We agree to notify AAS within 30 days of any changes to our Executive Director and contact person, address, phone numbers, email. 5. We agree to submit the annual self - survey report (current form available on the AAS website) to AAS by the end of February. Program Director ____________________________ Date Outside North America and Hawaiitc \l2 "Process Outside North America and Hawaii 1. Overseas requests will be accommodated when an experienced Surveyor already has personal or business travel plans at or near the requested geographical area if possible. 2. The fees will be at the rate of an initial accreditation, even when a re- accreditation is done. 3. The Surveyor will be reimbursed for their expenses relating directly to the site examination up to the rate paid of the organization. 4. All other accreditation Policies and Procedures apply.  Before proceeding with the application can you answer yes that you subscribe to and practice the AAS active rescue and active engagement policy in cases of an involuntary client, offer third party calls and follow up calls as highlighted in the Standards manual. If you cant you will not be qualified for accreditation. If you can, please proceed. One of the core values of AAS is that every person has the basic right to assistance in life-threatening or other crises. This value reflects the basic philosophy that an active rescue which includes; active engagement, active rescue, and collaboration should be implemented if a clients life is in danger even when the client will not or cannot assent. Because we also value a clients privacy and self-determination, ideally, the intervention is done in collaboration with the caller in the least invasive way. When that is not possible, the intervention will occur without the clients consent or knowledge, only after all other options have been exhausted. Some examples of proactive approaches for intervention and support of suicidal clients include; using caller ID, tracing, and calling police or ambulance, making follow up calls to suicidal callers and third party callers who are suicidal. AMERICAN ASSOCIATION OF SUICIDOLOGY Pre-Screening Questionnaire Please complete this pre-screening questionnaire by marking (X) on the appropriate lines beside each question if the question pertains to your service, center or program. If the answer to any of these questions is no, please explain on an additional page. Question Yes No 1. Does a corporate authority assume responsibility for the management of your program?   2. Is there a specific designated director of the crisis program(s) who serves at least part time in that capacity?   3. Are financial records kept in compliance with generally accepted accounting principles (GAAP)?   4. Is there designated office space for workers to answer the crisis line and/or interview clients?   5. Is there a written outline of pre-service training content, along with a bibliography?   6. Is there a minimum of 30 hours of pre-service training offered?   7. Is there a written plan for screening prospective crisis workers?   8. Do those with responsibility for the pre-service training have the experience, skills and competence to do so?   9. Are ongoing supervision and in-service training provided?   10. Is the telephone answered in person 24 hours a day, 7 days a week?   11. Is walk-in, face-to-face counseling available to clients through referral that is initiated by the telephone worker?   12. Are there arrangements to provide outreach, face-to-face services to those in crisis?   13. Does the program provide follow-up calls or services to suicidal callers?   14. Does the program complete an individual record for each caller/client at the time of their initial contact?   15. Is an assessment of lethality routinely done on all crisis calls and other crisis support services?   16. Are there written procedures for actively intervening in life threatening cases? (Please enclose.)   17. Are there arrangements to provide bereavement services to survivors of suicide?   18. Has the program adopted a written code of ethics?   19. Is someone in the organization responsible for dealing with requests for community education?   20. Is there a list (or database) that identifies general community resources?   21. Have program goals/objectives been identified in writing and is there evidence of their review and evaluation?   22. Does your center do outreach calls in third party situations involving suicidal risk? (Please enclose policies.)   23. Are there Online Emotional Services, Crisis Chat and/or Texting offered to individuals in distress or crisis?       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