Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) Rostering Application - Treatment Collaborative for Traumatized Youth

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

Do you hold a masters degree or above in a mental health discipline?*

Yes
No

License Number*

License State*

Proof of Degree*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Have you completed the TF-CBT web training (https://tfcbt2.musc.edu/)?*

Yes
No

Date of TF-CBT web training*

TF-CBT Web Training Certificate*

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Have you completed a TF-CBT face-to-face training with a nationally certified TF-CBT trainer?*

Yes
No

Face-to-face trainer name*

Face-to-Face Training Completion Certificate*

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Have you completed ongoing consultation calls or ongoing supervision as part of your TF-CBT training?*

Yes
No

Consultation call trainer name*

Consultation Call Completion Certificate*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Have you treated 3 children or adolescents with TF-CBT?*

Yes
No

Have you treated 2 children or adolescents with TF-CBT where there was active caregiver participation?*

Yes
No

Are you nationally certified in TF-CBT?*

Yes
No

National TF-CBT Certificate

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Message (Optional)

Name

This field is for validation purposes and should be left unchanged.