Honoring Children Mending Circles Trauma-Focused Cognitive-Behavioral Therapy (HCMC 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

Are you licensed?*

Yes
No

License Number*

License State*

If no, do you work on a team with licensed clinicians?*

Yes
No

Are you Alaskan Native?*

Yes
No

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*

Drop files here or

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

Have you attended and completed a 3-day training on HCMC?*

Yes
No

Training date*

Trainer name*

Trainer organization*

HCMC training proof of completion*

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

Have you completed consultation calls with a HCMC trainer?*

Yes
No

Call dates*

Call trainer name*

Trainer organization*

HCMC consultation call proof of completion*

Drop files here or

Max. file size: 8 MB.

Message (Optional)

Name

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