Fidelity Coach Certification Application Form

Fidelity Coach Certification Institute

Application to Participate in Fidelity Coach Certification
Tell us who you are an how to get in contact with you.
Name:

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Tell us about your professional experience.
Professional discipline
Agency
Position within your agency
Years working in Early Intervention
What are your current work settings?

Early intervention program (non public school affiliated) early intervention program (part of public schools) Preschool services Elementary school Hospital Home health agency Private pediatric therapy clinic
Which of the following practices do you use:

Coaching interaction style Natural learning environment practices Resource-based practices Primary service provider approach to teaming

Tell us about your plans to fulfill your role as an early intervention fidelity coach.
Why are you seeking this certification?
What is your interest in coaching other coaches?
Who will you coach?
What is your time availability to coach other coaches and how many coaches would you be able to coach per month?
Describe the administrative support or commitment you have for participating in this training, the six-months of follow-up activities, and to providing ongoing coaching of coaches related to the use of coaching and natural learning environment practices within and outside of your organization?
What is your plan for maintaining ongoing fidelity to coaching the coach practices?

Tell us about your philosphy and beliefs related to evidence-based early intervention practices.
Describe why you believe it is important to use a coaching interaction style with families and other caregivers in early intervention.
Describe the benefits of using natural learning opportunities and child/family routines as the context for intervention?
Describe the advantages/disadvantages of using resource-based intervention practices with families/caregivers.

Tell us about your level of prepardness for fidelity coach certification training.
Have you attended a Master Coach training taught by Dathan Rush, M'Lisa Shelden, and/or Kris Everhart ?

yes no
If you answered "no" to the question above, upload a 10-15 minute video of you coaching an early intervention practitioner.

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Fidelity Coach Certification Institute