Cognitive Processing Therapy (CPT) 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*

Mental health license information

License Number*

License State*

Have you completed the CPT web training (https://cpt.musc.edu/)?*
Yes
No

Date of CPT web training*
MM slash DD slash YYYY

CPT web training completion certificate*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Have you participated in and completed a live CPT training?*
Yes
No

Date of training*
MM slash DD slash YYYY

Trainer name*

Trainer organization*

CPT live training proof of completion*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Did you complete and participate in CPT consultation calls as part of your CPT training?*
Yes
No

Date of consultation calls:*
MM slash DD slash YYYY

Name of trainer on calls*

Trainer organization*

CPT consultation calls proof of completion*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

If the completion of your CPT consultation calls were more than 3 years ago - have you renewed your certification?*
Yes
No

Proof of certification renewal, if more than 3 years since trainings
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.