Alternative for Families Cognitive-Behavioral Therapy (AF-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

Have you completed and participated in an AF-CBT training session (~2-3 days)?*

Yes
No

Date of training*

Trainer name*

AF-CBT training session proof of completion*

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

Have you completed and participated in an AF-CBT advanced training session (~1 day)?*

Yes
No

Date of training*

Trainer name*

Trainer organization*

AF-CBT advanced training session proof of completion*

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

Have you completed and participated in AF-CBT consultation calls as part of your AF-CBT training?*

Yes
No

Date of calls*

Call trainer name*

Call trainer organization*

AF-CBT consultation call proof of completion*

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

Approximately how many cases have you used AF-CBT with?*

Did you complete a post-training assessment in AF-CBT after your consultation call training ended?*

Yes
No

Date of online assessment*

AF-CBT post-training online assessment proof of completion*

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

Are you nationally certified in AF-CBT?*

Yes
No

National AF-CBT Certificate

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Message (Optional)

Comments

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