Personal Information

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Proﬁciency Scale:

1 – Limited or no experience

2 – Experienced, but may need review or supervision

3 – Able to function independently

TREATMENT SETTINGS EXPERIENCE

Inpatient hospital psychiatric unit

Inpatient acute psychiatric facility

Chronic psychiatric facility

Outpatient clinic/community setting

Forensic unit (prison)

Eating disorder unit

Substance abuse/rehab unit

Locked unit/ward

EMERGENCY CARE EXPERIENCE:

Use of rapid response teams

Cardiac arrest/CPR

Airway management

Oxygen therapy

Oral/nasotracheal suctioning

Pulse oximetry

IV therapy

Start & maintaining peripheral IVs

Blood draw: venous

Infusion pumps

CLINICAL ASSESSMENT TOOLS EXPERIENCE - INTELLIGENCE ASSESSMENT

Wechsler Intelligence Scale (WAIS)

Wechsler Intelligence Scale for Children

COMMUNICATION TECHNIQUES EXPERIENCE:

Active listening

Restatement/reflection

Clarification

Focusing

Confronting

Summarizing

PSYCHIATRIC DISORDERS EXPERIENCE - MOOD DISORDERS

Major depression

Dysthymia

Bipolar disorder (manic-depressive illness)

Type I

Type II

PSYCHOTIC DISORDERS

Schizophrenia

Schizoaffective disorder

Schizophreniform disorder

CONGENITAL DISORDERS

Mental Retardation

Down’s syndrome

Cystic fibrosis

Cerebral palsy

Spina bifida

DEGENERATIVE DISORDERS

Alzheimer’s disease

Parkinson’s disease

Huntington’s chorea

EATING DISORDERS

Anorexia nervosa

Bulimia nervosa

Pica

SUBSTANCE USE/ABUSE EXPERIENCE

Withdrawal syndrome

Alcohol or ETOH

CIWA scale

Delirium tremens (DTs)

Wernicke-Korsakoff

SEXUALITY DYSFUNCTION EXPERIENCE - GENDER IDENTITY DISORDERS:

Paraphilias

Psychosexual dysfunctions

ELIMINATION DISORDERS

Encopresis

Enuresis

THERAPEUTIC APPROACHES EXPERIENCE

Psychotherapy

Behavior therapy

Milieu management

Relationship/family therapy

Electroconvulsive Therapy (ECT)

Crisis counseling

Behavior modification

Group therapy

AGE-SPECIFIC COMPETENCIES EXPERIENCE

School age (ages 6-12 years)

Adolescents (ages 13-21 years)

Young adult (ages 22-39 years)

Adults (ages 40-64 years)

Older adult (ages 65-79 years)

Elderly (ages 80+ years)

I certify that all the above information is correct, and that any misrepresentation or falsification of fact may be considered sufficient cause for immediate dismissal from the agency. I have filled out this skills checklist to the best of my knowledge and agree that all the information provided is correct.

Personal Information

Proﬁciency Scale:

TREATMENT SETTINGS EXPERIENCE

LEGAL/ETHICAL EXPERIENCE

EMERGENCY CARE EXPERIENCE:

SKILLED NURSING CARE EXPERIENCE:

CLINICAL ASSESSMENT TOOLS EXPERIENCE - INTELLIGENCE ASSESSMENT

PSYCHOLOGICAL TESTING

COMMUNICATION TECHNIQUES EXPERIENCE:

THERAPEUTIC INTERVENTIONS EXPERIENCE

PSYCHIATRIC DISORDERS EXPERIENCE - MOOD DISORDERS

ANXIETY DISORDERS

PSYCHOTIC DISORDERS

PERSONALITY DISORDERS:

CONGENITAL DISORDERS

DEGENERATIVE DISORDERS

EATING DISORDERS

CRISIS MANAGEMENT EXPERIENCE:

SUBSTANCE USE/ABUSE EXPERIENCE

DRUG USE/ABUSE

SEXUALITY DYSFUNCTION EXPERIENCE - GENDER IDENTITY DISORDERS:

CHILD/ADOLESCENT DYSFUNCTION EXPERIENCE

ELIMINATION DISORDERS

PERVASIVE DEVELOPMENTAL DISORDERS:

THERAPEUTIC APPROACHES EXPERIENCE

MEDICATIONS EXPERIENCE

AGE-SPECIFIC COMPETENCIES EXPERIENCE