Problematic Sexual Behavior Cognitive-Behavioral Therapy (PSB-CBT) Rostering Application

General Information
First Name*
Last Name*
Degree (ex. M.S., M.E.d)*
License (ex. LPC, LPCC)*
Personal Email Address*
Professional Email Address*
Personal Phone Number*
Agency Phone Number*
Agency Name*
Agency Address*
Agency City*
Agency State*
Agency ZIP Code*
Agency County*
Agency Type (ex. residential, inpatient, outpatient)*
Agency Website*
Treatment Information
Have you completed the TF-CBT web training (https://tfcbt2.musc.edu/)?*
- Yes
- No
Date of TF-CBT web training*
MM slash DD slash YYYY
TF-CBT Web Training Certificate*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.
Have you completed the video training series from the National Childrens Alliance (NCA) (http://www.nationalchildrensalliance.org/psb)?*
- Yes
- No
Date of video training completion*
MM slash DD slash YYYY
Proof of video training from NCA*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.
Have you attended and completed a PSB-CBT clinical training?*
- Yes
- No
Date of training*
MM slash DD slash YYYY
Trainer name*
Trainer organization*
PSB-CBT training proof of completion*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.
Did you complete and participate in PSB-CBT consultation calls as part of your PSB-CBT training?*
- Yes
- No
Date of consultation calls*
MM slash DD slash YYYY
Name of trainer on calls*
Trainer organization*
PSB-CBT consultation call proof of completion*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB.
How long have you been using PSB-CBT?*
Approximately how many families have you used PSB-CBT with?*
Message (Optional)
Comments
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General Information

Treatment Information