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TCTY@sanfordhealth.org

Contact Us Roster Applications

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STATEWIDE PROGRAMS
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RESOURCES
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ABOUT US
STATEWIDE PROGRAMS
TRAINING
TREATMENT
AGENCIES & CLINICIANS
- Agencies
- Clinicians
RESOURCES
Find A Clinic

Child and Family Traumatic Stress Intervention (CFTSI) Rostering Application

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Child and Family Traumatic Stress Intervention (CFTSI) 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 participated in and completed a CFTSI 2 Day Training?*
- Yes
- No
Date of training*
MM slash DD slash YYYY
Name of trainer*
Trainer organization*
CFTSI 2 Day Training Certificate*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.
Have you completed Consultation Calls with a CFTSI Trainer?*
- Yes
- No
Date of calls*
MM slash DD slash YYYY
Call trainer name*
Call trainer organization*
CFTSI Consultation Call Certificate*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.
Message (Optional)
Phone
This field is for validation purposes and should be left unchanged.

6424

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